Twice Upon A Time by film-maker Niam Itani: for the refugee children of Syria and Lebanon

Lebanese film-maker Niam Itani - read a wonderful interview with her here - is working on a new documentary project about Syrian and Lebanese children, called Twice Upon A Time, which, as she tells me, "seeks to raise hope amongst refugees and parents of today." Itani has started a campaign page to raise post production funds for Twice Upon A Time and produced a trailer introducing viewers to Khalil, the charismatic and bright boy at the heart of the film:

There are only five days of the fundraising campaign left, and nearly $20,000 still to be raised for this important, humane and uplifting film project.

Niam Itani was born and raised in Beirut and Ghazzeh in Lebanon. The Lebanese Civil War lasted 15 years, consuming 9 years of her childhood. "I witnessed several periods of unrest and violence in Lebanon throughout my childhood and adult life," she tells me. "I’ve had to abandon my city and home with my family several times due to these conflicts; the longest of which lasted five years in the Bekaa Valley - a rural area of Lebanon - in a village called Ghazzeh."

Twice Upon A Time is a film drawing together themes with both political and personal resonance, highlighting the universal impact of war on children and on entire communities. In the campaign briefing Niam Itani writes the following:

"In 1989, my parents left Beirut for a small village in the Bekaa Valley called Ghazzeh. I was eight years old.

"In 2012, Khalil's mother left Syria and took refuge at our house in Ghazzeh. Khalil was ten years old.

"This film tells the story of my friendship with Khalil, and our efforts to find hope and joy in the midst of madness and despair. It is also a personal reflection on childhood, nostalgia, home, belonging, memory and war."

Khalil & Niam assemble kites together, Spring 2013

"The Lebanese Civil War (1975-1990) left behind an estimated 120,000 fatalities. A study conducted in 1992 under the title 'Assessing War Trauma in Children: A Case Study of Lebanese Children' showed that 'on average a Lebanese child has experienced five to six different types of traumatic events during his or her lifetime; some events were experienced several times.' (Journal of Refugee Studies, 1992, Macksoud)

"Twenty-three years later, in what I'd like to think of as a civilized and sophisticated world that we live in, another armed conflict took the same trajectory as the Lebanese one, with more horrifying outcomes. By September 2013, less than three years after its beginning, the Syrian Crisis had left more than 120,000 fatalities and 2 million refugees. The numbers grow on a daily basis. [Read my own coverage of the Syrian humanitarian crisis here.]

"Seeing these two conflicts happen in such a short period of time in history and in two neighboring countries is heart wrenching for me. The most devastating part is that I am forced to watch more children grow in the same damaging conditions that my generation grew up with.

This is not another film about children who are orphaned, hungry or homeless seeking food and shelter during war. This is a film about children with caring and loving parents, coming from middle class families like most of us, but finding themselves in the cruellest human condition of all: war."

Khalil & his siblings pose for a photo before school, Spring 2013

"By telling this story, I hope to bring more understanding and awareness about this issue and to mobilize additional psychological and material support for children refugees around the globe.

"On July 31st, 2012, Khalil's family crossed the Syrian Border into Lebanon to flee the armed conflict in their country. My mother gave them refuge at our summer property in Ghazzeh, in the Lebanese countryside. That is where I met Khalil (12 years) who would later change the course of this project, and therefore, my life.

"But the journey of this film started much before the arrival of Khalil's family to Lebanon, and before the Syrian Crisis altogether.

"It began in 2010 as an attempt to fill memory blanks pertaining to my childhood during the civil war in Beirut. I was searching for "nice memories" during the period between 1980 and 1989, which seem to have vanished from my memory."

This photo of Niam was taken on May 4, 1984, one month before her sister 

Heba (mentioned in the video) passed away at the age of 9

"During our regular visits to Ghazzeh every weekend in 2012, I started to help my mother in providing food and shelter to refugee families. It didn't take long to notice that the plight of refugees in the village was too identical to our own strife in the exact same place, two decades earlier.

"Since Khalil's family technically lives with us, an unorthodox but very special friendship grew between me and him. My witnessing of his daily struggle in the beautiful locale of my childhood served as a wake up call for me. I felt that Khalil was re-living my past right in front of my eyes. And this time I could document it, not only for myself but for the whole world.

"Something was urging me to bring my camera and film the bond that was developing between me and Khalil. A bond built on sharing the war related traumas and many common personality traits. As in many other documentary projects, when I first started to film I didn't know what I was specifically after, but the pieces quickly started to fall in place."

 

Aya (3.5 years old) is a one of the Syrian refugees in Ghazzeh

All principal filming on Twice Upon a Time is now complete. To arrive at this point, Niam has used her own resources and those of her family, friends and friends of friends. The "urgency, intuitiveness and unfolding of the story on a day-to-day basis", she says, obliged her to focus on shooting the film rather than file applications for production support and/or waiting for financial backing from film funds or institutions (which is the classic route). The film team now need your support to raise a minimum of 35,000 USD for this project. These funds will cover part of the post production process and allow them to hire an editor, a sound designer and other artists and technicians to create a fine cut of the film. Once they have that fine cut, they can use it to apply for post production funds from regional and international film bodies.

Niam Itani has been campaigning and advocating for Twice Upon a Time, speaking on Al Jazeera about both her own history, Khalil's experiences and the project:

When I became aware of the project, via an introduction from film-maker Marian Evans, I had to find out more about this skilled and impassioned artist, who studied  for her BA in Communication Arts and a Masters Degree in Education from the Lebanese American University in Beirut, then pursued an MFA in Screenwriting from Hollins University in Virginia, USA. She made her first professional documentary in 2001 for a conference at university when she was an undergraduate. It was a short film entitled Ghareeb (Stranger). In 2005 Itani completed a second short documentary, Zakira Mubsira (A Foretold Memory). Between 2005 and 2010, she got the chance to expand her documentary skills while working at Al Jazeera Channel in Qatar as a Programs Producer. At Al Jazeera Itani worked as assistant producer on the critically acclaimed series Al Nakba and went on to make her first feature documentary, Rokam Al-Bared (Ruins of Al-Bared), a documentary about the destruction of a Palestinian refugee camp in North Lebanon. Her last short film, Super.Full. (2010), played at several film festivals including two Academy Award Qualifying festivals and the Venice Film Festival. Itani's feature narrative project entitled Shadow of a Man, is currently in pre-production and has been selected at multiple regional and international film venues. In January 2013 she co-founded placeless films, a film production company in Beirut, Lebanon. As part of placeless films, Itani also recently launched ScriptExperts, a specialised story & script service catering primarily to writers and filmmakers in the Middle East.

Niam Itani told me more about her intentions as the creator of Twice Upon A Time. Below are selected quotes from her exclusive, honest and powerful interview:

"The original idea was a personal documentary project, that I started to work on in 2010 – a journey to document my own memories as a child, some of which were very vivid and some missing. I was going to interview family members mainly and try to fill in the memory blanks. This idea took a major turn; however, when Syrian Refugees started coming into Lebanon in 2012. The uncanny similarity of circumstances forced me to shift my focus to the “story” unfolding right in front of me in the present. A present that will be embedded in the memories of this new generation of children refugees. Twice Upon a Time was born."

"[As explained above,] the film is the story of my friendship with Khalil, a Syrian boy who had to leave Syria with his family in 2012, and took refuge in Ghazzeh (the village where we took refuge in 1989) as well. On a second level, it is the story of Khalil’s family and their recent experience of refuge and the story of my family’s experience of refuge 23 years ago and how similar are the challenges that we used to go through as children. On a third level, this is a film about hope, memories, childhood, nostalgia, and the notion of home."

"The film seeks to bring many issues to the fore. Some of them are everyday issues of refugee life like finding shelter, food, health-care, schools and a good environment to live in whether on the level of infrastructure or on a social/interpersonal level, and potential work and education opportunities for family members. Important issues that I want the film to call attention to is the children mental and psychological health during refuge, protecting them from witnessing additional trauma, and encouraging them to have hope, to give them opportunities to play and to pursue their education and bring their dreams closer to reality. Another major issue is the lack of compassion for the incoming refugees among host societies – Lebanon in particular. We won’t be delivering any of these messages to our audience but want them to see for themselves."

"The sources of hope for the Syrian children today lie within us, those who were children during times marked by war, hatred and destruction; and yet we made it to become successful and active individuals in our society today. I’d like to think that I give hope to Khalil when he appreciates what I do today and realizes that I lived most of my childhood years in conditions similar to what he is living through now. Hope lies in sharing the lessons that we learned from our own war, and stressing the importance of education, understanding others and working towards a better future."

"The film is a very personal and intimate story. In the film, the main people who speak are Khalil (he talks to me), myself (through narration and through talking to him), his mother, and my mother. We are exploring ways of partnering with International NGOs to carry this message through a concerted campaign, to raise awareness among both host societies and refugees, particularly across Lebanon, Jordan, Turkey and Syria. While this is the grand plan, we need more players and commitment to make this happen. On a more granular level, my sincere hope is that this film will touch people, irrespective of where they are, by sharing the message of understanding and compassion on a more individual human level."

"Mahatma Gandhi once said, 'If we are to teach real peace in this world, and if we are to carry on a real war against war, we shall have to begin with the children.' I have witnessed war as a child. Once it marks you, it will be very difficult to erase that mark. So the best thing to do is to utilize that effect and make it a tool for peace, love and understanding."

"I would like for viewers to put themselves into the shoes of the refugees, even if it is only for one day or one hour, and take into account the life that they must’ve been forced to leave behind. Their arrival as refugees in a new town or a new country is marked mostly by more hardship and challenges at the very basic level. I want this film to break many stereotypes, to spur people in societies that have refugees to accept them as fellows in humanity, to smile at them – if not for anything else. Ideally, I want people to help refugees wherever they are, to encourage them and support them in any way possible. We were there yesterday, they are here today, nobody knows who it could be tomorrow."

"I would like to bring a future of stability and safety to the children of Lebanon and Syria. One where bombs and bullets are considered dangerous accidents, not everyday life happenings. I want them to have the luxury to play and study without being forced to grow up so fast and carry more responsibilities and burdens than they are forced to do now."

Niam Itani with Khalil

The fundraising campaign for Twice Upon a Time is here. There are just five days left. If you like what you've read here, please support this vital project, which speaks to all those across innumerable countries, generations and cultures who have suffered displacement, conflict, societal breakdown and the fallout of violence and find themselves having to forge new lives as strangers - often traumatised, often mistrusted - in new places. 

With gratitude to Niam Itani for granting me her time and wisdom. Quoted campaign text (c) Twice Upon A Time.  Bidisha is a 2013 International Reporting Project Fellow reporting on global health and development. 

Nutrition and maternal, newborn and child health: joining the dots and looking beyond the Millennium Development Goals

A news bulletin sent around earlier this year by Dr Carole Presern, Executive Director of The Partnership for Maternal, Newborn and Child Health, threw down the gauntlet for the world community. At the time of the G8 summit – which I covered here in relation to the Enough Food For Everyone IF… campaign – the PMNCH highlighted the importance of nutrition. Since then I have found the work and the general approach of the PMNCH to be invaluable in joining the dots between various global health and development issues now that world leaders and development workers are considering a framework for initiatives extending beyond 2015.

The result of this summer’s discussions and presentations was the signing, by numerous international players, of the Global Nutrition forGrowth Compact, with up to $4.15 billion committed on this initiative up to 2020. Those who contributed to this strong pledge for a reduction in under-nutrition included the Bill and Melinda Gates Foundation, World Vision and Save the Children.

As Dr Presern writes,

Leaders should be especially motivated to see pledges result in measurable action. Bringing commitments to invest in nutrition under the umbrella of the Every Woman Every Child movement led by UN Secretary-General Ban Ki-moon would provide a useful framework for tracking their progress. We look forward to supporting efforts in this direction.

All of these issues are already very high on the international agenda. At the 66^th meeting of the World Health Assembly in Geneva in May this year, global delegates passed a resolution to implement the recommendations of the United Nations Commission on Life-Saving Commodities for Women and Children and also discussed a first-ever action plan pertaining to newborn health to end preventable deaths, which will be realised at the 2014 World Health Assembly.

At the Nutrition for Growth event in June, Justine Greening MP from the Department for International Development spoke about the importance of nutrition as a major development issue. She also outlined the financial pledges made by the international community of leaders in politics, social enterprise and business. She added,

Under-nutrition is stopping children and countries from reaching their full potential, accounting for the loss of billions of dollars in productivity. A strong and healthy workforce is vital if a country’s economy is to prosper. This means business and science taking a lead in fighting for good nutrition because we understand that better nutrition is the smart way to tackle extreme poverty, child mortality and economic underachievement.

What has to happen next is an integration of understanding between the issues – and, I would argue, an analysis of how gender inequality and sexist social values underpin many of the disadvantages, risks and problems covered.

The PMNCH’s own research provides a nuanced analysis of the relationship between nutrition, sustainable development and women’s and children’s health. Their findings were developed for the Open Working Group of the UN General Assembly in preparation for the formation of post-2015 development plans. They make a strong case for the importance of investment in nutrition for women and children as a major factor in ensuring sustainable development and its four pillars of economic development, environmental sustainability, social inclusion and peace and security; these criteria having been delineated by the UN System Taskforce on Sustainable Development.

This is about more than being hungry or not getting the right vitamins or minerals. Malnutrition and under-nutrition, rooted in long term poverty, inequality and disadvantage, have wideranging and interconnected health, social and economic consequences which do not affect just individuals but entire families, communities and generations. Their finding – spelled out in greater detail here, with references to specific studies – demonstrate myriad risks of malnutrition.

The report states,

Malnutrition contributes to disease and early deaths, especially for women and children. Malnourished women have lower birth weight babies resulting in children born into unhealthy, poorer families… and a lifetime of nutrition-related morbidity and mortality, which affects a woman’s own health and productivity and that of her offspring.

What is particularly interesting about the report is that it doesn’t just chronicle a problem, it also points to the benefits of action, stating that improved nutrition and greater health result in higher productivity. The findings are that women who are healthy, fed and working participate in the economy from a stronger position, both saving and investing. Healthy, well-nourished children have better mental development and learning skills and are more likely to stay in education and therefore to have a greater chance of earning more. The report points out that those who did not receive adequate nutrition in utero and in their earliest years “has been associated with reduced labor supply” and consequently lower adult incomes and therefore lower productivity at a mass level, across countries, where under-nutrition is widespread.

Whether or not you agree with this approach – that we should nourish human beings because they’ll then nourish capitalism more heartily instead of lying there like non labour producing duds - rather than seeing this as a human rights issue – it’s an interesting insight into the dramatic difference something as basic as nutrition can make.

There is also the cost of treating malnutrition:

• In some  low-income countries, the direct costs of iron deficiency (disease and death) are as high as 0.57% of  GDP, while indirect costs (related to physical and cognitive losses) can reach 4% of GDP.8

As a final thing to think about, the PMNCH also considers the risks and consequences to the health and the economy of too much food (and of the wrong time), not just too little food. In environments where the issue is not lack of food but over-consumption of food which is not nutritional and involves many risky factors (processed and refined food, food containing many additives and few nutrients, food high in salt, sugar and trans fats) there is an ever-rising figure, currently up to 8% of healthcare spending, associated with obesity. In China, right now, the cost of dealing with obesity is actually more than the economic costs associated with under-nutrition.

Related articles:

• The power of simplicity: reducing maternal mortality in Sierra Leone and Burundi
• Help the mother, help the child, secure the future: maternal and child health in India
• World hunger: time is running out

 Bidisha is a 2013 International Reporting Project Fellow reporting on global health and development.

When free universal healthcare isn't free and isn't universal: a case study in TB treatment from Burkina Faso

As the term of  the current Millennium Development Goals reaches an end in 2015, healthcare workers and reporters worldwide are assessing the efficacy of different global health and development approaches over the last few years. The necessity of improving global health has been one of the highest priorities of development practitioners and activists, the touchstone being universal access and free access.

One project study, which aimed to provide free treatment for tuberculosis patients in Burkina Faso, caught my eye because it illustrates the subtle challenges and difficulties (as well as areas of success) which arise when it comes to the practicalities of delivering healthcare which is intended to be both free and universal. The findings of the research will be vital in shaping world healthcare policies when it comes to the treatment, control and prevention of TB after the timeframe of the current Development Goals.

Based on meticulous year-long research by Samia Laokri, Olivier Weil, K Maxime Drabo, S Mathurin Dembelé, Benoît Kafando & Bruno Dujardin, the study - an abstract is provided here by the World Health Organisation - demonstrates the flaws of a generalised or sweeping analysis, starting with the "theory [that] the removal of user fees puts health services within reach of everyone, including the very poor." They warn,

In the poorer countries of the world, where most people live on less than US$ 2 per day and expenditure on health care can plunge patients and their families into extreme poverty, the removal of user fees for health is seen as a matter of real urgency. Unfortunately, this is unlikely to be enough to ensure truly universal coverage.

A full version of the report is here and I have provided my overview and analysis below. 

The study I'm focusing on, which is part of a larger project [see points seven and eight here], is based on the findings of rounds of interviews with 242 patients who tested positive for pulmonary tuberculosis across the six rural districts of Bousse, Koupela, Ouargaye, Zabre, Ziniare and Zorgho and who were enrolled in the national TB control programme. As the writers state,

The median direct costs associated with tuberculosis were estimated at 101 United States dollars (US$) per patient. These costs represented 23% of the mean annual income of a patient’s household. During the course of their care, three quarters of the interviewed patients apparently faced “catastrophic” health expenditure. 

Their analysis of the cause of this US$101 direct cost is interesting: around US$ 45 of the cost was not down to the inherent cost of the medicines or treatments themselves, but to failures in the broader health system and policies; the researchers cites access, medical consultations, out of pocket expenses, unofficial payments to medical professionals and lost wages from their day jobs for both diagnosis and treatment (or even redundancy due to repeated absence). While individual patients bore these costs by strategising. economising and accommodating within their households and negotiating or receiving community and extended-family support, this accommodation weakened their overall economic standing and jeopardised their position in the long term. There was a likelihood of established savings being used, of families being forced to decrease consumption to save money, being forced into the sale of goods or services to raise money or to take out loans to raise money. When this seemingly small monetary figure accounts for nearly a quarter of each household's income, given the generalised socio-economic context of poverty or near-poverty amongst the population studied, there are grave consequences in terms of increased social inequality and economic instability; the stigma of suffering from TB; the 'social debt' incurred by help received by family members and the wider community; and a greater improbability of proper treatment being sought, for all these reasons. The illness itself increased instability, with the researchers citing an average loss of 45 days of work lost by sufferers across the research year from 2007 to 2008. 

The 23% percentage figure of annual income cited for TB treatment costs is alarming as the threshold for a definition of "catastrophic" expenditure which represents an excessive burden on a patient or their household in the rural low-income communities in the study, is 10%. The study analysed all the types of expenses and costs, including non-medical and non-financial costs, which arose as a result of suffering, diagnosis and treatment and identified various failures and weaknesses in the system. They include necessary services that were not covered by the free treatment package (which include diagnosis by spit sample, anti TB drugs and repeat smears to determine treatment outcome) and services that were not necessary but where payment was required. The report states,

Only 2% of the patients interviewed...reported that they had received completely free tuberculosis care. 

The challenges above, as well as other failures in patient treatment (such as extended time periods required for diagnosis and repeat procedures) explain why the rates of TB detection and cure are lower than might be hoped given the MDG and the adoption of international recommendations for TB control. The researchers state that what are necessary are solutions which pull in all practitioners, "political decision-makers, managers of health programmes and health services" to develop meaningful responses and suggest a number of measures including the decentralisation of diagnosis and treatment so that patients do not have to travel, improving community care to enable early detection, help for the poorest households, supporting healthcare providers and also supporting patients not just financially but socially and psychologically through dialogue with former patients. They also call for a rigorous assessment of 'free' healthcare systems with a multilayered analysis of economic and social consequences aimed at fine-tuning policy, identifying and rectifying faults in the system, guaranteeing efficiency and helping (rather than exploiting or exacerbating the problems of) the most vulnerable.

Bidisha is a 2013 Fellow for the International Reporting Project. She is reporting on issues of global health and development. 

The power of simplicity: reducing maternal mortality in districts in Sierra Leone and Burundi

Following my piece about maternal health in India, and in advance of the UCL symposium on community-based global maternal care next week, I wanted to focus on two smaller-scale success stories and examine what makes them work. Medecins Sans Frontieres has been working on two projects aimed at reducing women’s risk of death in childbirth in the Kabezi district in Burundi and the Bo district in Sierra Leone.

MSF has produced an analysis of the challenges and gains of its work in a report called Safe Delivery (link takes you to a short précis) which looks at their work in Kabezi since the 2006 start of the project, and in Bo since the MSF began running a hospital there in 2003.

Image taken for MSF by Sarah Elliott, showing a successful emergency
birth in Burundi - I love the woman's smile.

Both Sierra Leone and Burundi are at a disadvantage when it comes to maternal care as their health infrastructures – along with much else – have broken down during and in the aftermath of civil war. The long effect of such breakage is a deficit of human, educational and practical resources: so medical facilities are needed, as are qualified healthcare workers, as are the systems to employ them in a sustainable way and the educational infrastructures required to train them. This is before we tackle the important issue of patients’ own access to healthcare and the importance of antenatal and postpartum care. All this requires investment, establishment, organisation and management. According to MSF Burundi has a national average of 800 maternal deaths per 100,000 live births, and Sierra Leone has a national average of 890 maternal deaths per 100,000 live births. Sierra Leone has the third-highest rate of maternal death, after Chad and Somalia. The main causes of maternal death are haemorrhage (25%), sepsis (15%), unsafe abortion (13% - and the report states clearly that “abortions need to be performed by skilled medical workers in a safe and hygienic environment”), hypertensive disorders like eclampsia and pre-eclampsia; and obstructed labour.

As the report – which can be read in full here - states,

Every year, some 287,000 women die [globally] from complications during pregnancy and childbirth. Most are young, active and healthy. And for every woman who dies, another 20 women suffer from chronic ill health or disability due to conditions such as obstetric fistula.* 

Across the world, in every country and every  population group, approximately 15 percent of  pregnant women develop complications that are potentially life-threatening. But the fate of a  pregnant woman is very much dictated by where  she gives birth in the world. In fact, 99% of  maternal deaths occur in poor countries, where – for many people – medical services are out of reach or simply unaffordable

Yet the local district projects  (serving a population of nearly 600,000 in Bo and just under 200,000 in Kabezi) have shown that when addressing this issue the implementation of basic – or rather, obvious – measures has steeply reduced rates of maternal death. The report stresses that the problem is not a lack of “state of the art facilities” and shows how the establishment of an ambulance system and the availability of emergency in-hospital emergency obstetric care, with trained staff and appropriate medical supplies, twenty-four hours a day, for free, have brought the Kabezi figures down to 74% less than the national level for Burundi and the Bo figures down to 61% less than the national level for Sierra Leone. In both cases the cost of providing such measures to the population for free is less than 2 Euros per head in Bo and a tiny bit over 3 Euros in Kabezi.

One of the UN Millennium Development Goals is to reduce maternal mortality (in comparison with figures from 1990) by 75% by 2015. Judging by the success of the projects I’ve described above, extreme change is possible through the implementation of simple but profoundly important measures. As the report states,

A common assumption is  that improving access to emergency obstetric care is too costly, but MSF’s experience shows that this need not be the case.

*Despite the triumphs of the two projects I’ve described, in February of this year MSF released a press alert announcing that Burundi’s only free provider of treatment for obstetric fistula, which is caused by complications during childbirth, is under threat of close due to a lack of trained medical staff. The Urumuri Center, in the city of Gitega, is run jointly by Burundi’s Ministry of Health and MSF and treatment is provided by foreign volunteer surgeons on short-time assignments.


Bidisha is a 2013 Fellow for the International Reporting Project. She is reporting on issues of global health and development. 

Help the mother, help the child, secure the future: maternal and child health in India

Photo (c) Children In Need India

Like many people ‘of colour’, I am occasionally subject to a random dousing of imprecise and pejorative cultural clichés by ignorant people with a superiority complex, just like a delicate lotus blossom caught in a balmy, allegorical, toxic monsoon shower.

Woman in publishing, at literary festival: “What do you do?”
Me: “At the moment I’m working with the Gates Foundation and Johns Hopkins University, reporting on international development? No, before you ask, I haven’t met the Gates’s. The next thing I’m doing is on maternal health, I think. It’s really interesting.”
Woman in publishing: “Oh! That’s so interesting because the other day I was thinking to myself, I had trouble with my two pregnancies and if I’d been having my babies in the developing world, I wouldn’t have survived. Do you know [random British Asian woman in publishing PR]? Because you look like her and you remind me of her.”
Me: ???

I have no doubt that I in no way resemble the one other Asian person Publishing Woman has met in her working life. Poor PW, we met for 10 minutes out of nowhere and she couldn’t stop talking about race, refugees, poverty and the pathetic ills of the ‘developing world’ – it’s like she had racial Tourettes. And had I been able to recover from the speechlessness that afflicted me at the crucial moment, despite the fact that I talk for a living, I would have asked her which country exactly in ‘the developing world’ (which bigots usually take to mean everywhere or possibly anywhere from Senegal, across Libya, Somalia, Congo, down to Mozambique, then up through Iraq, Iran, Afghanistan, Uzbekistan, definitely India, Pakistan, Bangladesh, Sri Lanka and then possibly through to rural China perhaps… and maybe Burma, or rural Indonesia…and maybe also acrossways to some countries in South and Latin America, oh and the Caribbean islands maybe too, and gosh even some parts of Greece?) she meant, and then which region in which country.

The whole thing – or rather, her gloating and ignorance – made me think of an article I wrote a long while back, about Children in Need India. I described ‘two Indias’: that of the extremely numerous privileged middle class, who have the finest education, prospects, family support, influence, connections and healthcare; and that of the poorest, who despite the general dynamism, ambition and industry of today’s India still suffer due to lack of access to healthcare, education, influence, rights and justice. So often, it is only the second India that the wider world sees. It pains me, as a British Indian, that the rest of the world is blind to the incredible humour, energy, intelligence, broadness and enlightenment I see everywhere in India. In many ways, as a woman I find Indian culture much more sisterly and infinitely less misogynistic, judgemental, brittle, sleazy, objectifying, ageist-sexist and dollybirdish than British culture – but that’s a subject for another article.

Still, when it comes to society’s least advantaged, there are certain issues which cannot be ignored. India has a population of around 1 billion people and poverty, hunger, illness, gender and class injustice, lack of access, lack of rights, abuse, exploitation and geographical isolation from sources of both power and assistance (such as healthcare) are disproportionately weighted against those with the least. In short, despite India’s great achievements and many distinguished citizens, there are still an awful lot of poor, disempowered, ill and hungry people.

Looking back through Children in Need India’s work since I wrote that first 'two Indias' article, it is clear that solving the most fundamental problems must start from birth. I was intrigued by CINI because it started up with just two clinics for deprived children in Kolkata, where my mother’s family are from, and has since grown into a much larger organisation operating in West Bengal.

They present some sobering statistics, from Unicef studies:

• Infant mortality is highest in India than anywhere else in the world. According to Unicef’s 2010 figures, the majority of the 6,000 children who die in India every day, the majority are from preventable causes.
• Almost a half of all children under the age of five in India are clinically malnourished (Unicef study, January 2012)
• According to Unicef’s 2005 figures women in India are 80 times more likely to die during childbirth than in the UK due to lack of access to basic healthcare and monitoring during pregnancy for poorer women, as well as malnutrition and anaemia, which are linked.

There are further statistics – all, sadly, predictable – relating to rates of child labour, the possible consequence of exploitation and abuse of children who labour, the young age of girls’ marriage in rural areas, relatively low rates of child education (education in India is now free for all but uniforms and books can be expensive) and the knock-on effect in terms of adult literacy and, of course, gender equality.

This month the Wilson Centre in America held an extremely wide-ranging conference on Maternal Health in India: Emerging Priorities. There is a brilliant sum-up and full footage of the conference here. Taking place across New Delhi, Boston and Washington, the speakers argued strongly for the issue of maternal health to be seen in the context of multiple underlying social, health and economic factors, pointing out the importance of various key factors. First, more attention must be paid to women's health after giving birth - focusing on morbidity, not just mortality - and ensuring that all of a woman's health needs, from family planning to sexual health, are met in the same (geographical) place by the same people or organisation. Second, there must be an understanding of he importance of family planning: fewer pregnancies, with longer gaps in between, are better for women's physical and mental health and the health of their babies. And third, the importance of post-partum health care and sustained treatment cannot be underestimated.

Underlying all of this are the effects of gender inequality on women's health: early marriages leading to early and numerous births; violence against women; the underprivileging of female family members when it comes to feeding/serving, leaving women with the worst and least food (leading to malnutrition and anaemia) and the most and hardest labour within the house and beyond it. Class is also a powerful influence on Indian women's access to healthcare: disenfranchisement due to caste or other low class status is serious and widespread.

When it comes to healthcare, the best work is done through direct outreach, local engagement and the creation of long term relationships and structures: in one film, CINI describes visiting people door to door, inviting local people to meetings, the setting up of ‘panchayat’ council meeting where citizens speak up about what they need and are also educated and informed of their rights. In this way, the fundamentals – health, education, nutrition – are slowly strengthened. One intriguing project, which kills two birds with one stone (so to speak… actually it gives life to two birds with one stone…) is the ‘Nutrimix’ nutritional project: this is a pre-mixed nutritional food supplement which benefits Under-5s, which is sold by women to their local communities at a low price, but with a  small profit. It incentivises the women to sell and benefits them financially, while also aiding child health.

Other solutions are more traditional, like drop-in clinics giving advice on prenatal care, nutrition, vaccinations (one doctor talks positively about the success of the polio vaccination project at her clinic – once mothers see how simple it is, they are bringing as many local children as they can), reproductive health and more. Still, the strong theme of gender inequality, sexual exploitation and hypocrisy cuts through all of these issues. The clinic deals with STI’s, among other things, and it is left tactfully open as to where the STIs come from (hint: it’s not the women). Many of the women having babies are under-nourished because, even in a generally poor family, the men and boys will be privileged and the mother will eat last. In the film, one doctor at a baby clinic gestures to a patient and points out that the woman (and by consequence her baby) is under-nourished and in frail health because, due to a lack of contraception and consideration from her husband, she has too many children, who she can’t feed and is visibly too exhausted to look after.

Still, it is these same women who are finding a voice. From the seemingly small act of seeking and receiving healthcare treatment they are empowered to take a stand not only in their local area – one example is of women going door-to-door and educating their neighbours about the importance of environmental health and sanitary local conditions, which help to prevent the spread of germs – but also speaking out against the marrying-off of girls at a young age and insisting on the right for all children, whether they are boys or girls, to be educated. They are also empowered to demand safe and adequate healthcare. As one woman says: “We also want all mothers to be able to give birth in a hospital, without the risks of a home birth.”

Bidisha is a 2013 Fellow for the International Reporting Project. She is reporting on issues of global health and development. 

Indonesia is just one example: introducing the International Year of Water Co-Operation

Image (c) UN

World Water Day was just a few weeks ago, on 22^nd March, and this time around it’s part of 2013’s special International Year of Water Co-Operation. While I’ll write more about water, health and development in coming months, the poster below gives some impression of just how many individuals, informal groups, charities and organisations have been active in the fight to provide universal, accessible, clean and safe water for all the world’s population on World Water Day. 

Image (c) UN

At the same time, world leaders are meeting throughout the year to seek ways to co-operate and fund initiatives to make these goals a reality for everyone. On World Water Day itself there was a High Level Forum at the Hague and a High-Level Interactive Dialogue (love those crushingly literal antieuphemisms!) at the UN headquarters in New York and other summit meetings are planned in Stockholm, Tajikistan and Norway throughout the year.

To give some idea of the considerations and challenges which arise when looking at water and development I want to take USAID’s work in Indonesia as a case study, based on recently released details of their initiatives there as part of the $33 million, five-year IUWASH (Indonesia Urban Water, Sanitation and Hygiene) Project. In support of the country’s Millennium Development Goal (MDG) regarding improvements in water provision and sanitation, IUWASH reaches out across more than 50 municipalities, helping up to 2 million people in urban areas access safe water and improving sanitation for many others

According to USAID,

• Around 40% of Indonesia’s urban households have access to clean water
• Just over 50% have basic sanitation
• In all, 75% do not have “adequate sanitation”
• Poorer families are disproportionately affected – so, as in so many places, there is a gap in privilege, resources, access, opportunities and advocacy (that is, the clout to be heard and make social changes) between the richest and poorest. 

The principal barrier to safe, piped water in urban areas in Indonesia is financial: the installation and connection charge of between $150 and $300 might be as much as three months’ an average earner’s salary – USAID cite a typical example of a vegetable seller and mother of two from Jiyu, earning $2-$3 a day which barely covers essentials as it is. For those without access to piped water, water must be collected and carried from the nearest river or reservoir, a task which is extremely arduous, time-consuming and inefficient. One person can only bring as much water as they can carry. This must be shared amongst the family and amongst cooking, bathing and clothes-washing requirements.

A further difficulty is that in the implementation of a piped water network, a number of processes, vested interests and various groups must be aligned. Strategy, goals, budgets, funding, decisions and policy come from the government, with or without the collaboration of other governments, agencies or funds internationally; geographical planning, irrigation, building and the establishment of utilities, sanitation and facilities will all be handled by private businesses and so on.

Photo (c) USAID Indonesia project

With access achieved, the next issue to tackle is sanitation. USAID estimates that in Indonesia

• only about 2% of urban households are connected to sewerage systems
• up to 18% of urban dwellers must defecate openly, without facilities for the removal of waste

Here, the solution is consciousness-raising about sanitation issues and good practice, people’s unity in improving conditions for everyone and the importance of local leadership in effecting change among multiple households, encouraging families to build improved sanitation facilities like latrines, practice good hygiene (which can be as simple, but effective, as hand-washing, medicated cleaning products and the separate of areas for different tasks). The swift and obvious success of these often-simple measures – such as a steep decrease in rates of diarrhoea and an increase in general health – often inspires communities to go further in terms of grassroots local development, towards recycling and composting.

This is achieved through all parties pulling their weight. IUWASH and similar initiatives must bring together all these different parties to ensure long-term planning and delivery and create a new, different, sustainable future.

Bidisha is a 2013 Fellow for the International Reporting Project. She is reporting on issues of global health and development. 

Indian court rules that you can’t hold the developing world to ransom when it comes to medicines that would save millions of lives

I just saw this on the BBC and had to cover it because it highlights some of the many issues surrounding patients’ access to effective long term medical care in the developing world, illustrating how the humanitarian issue of global health can become subject to issues of profit, politicking and power.

The Swiss pharmaceutical company Novartis has had its patent application for a newer version of an already-available, expensive and effective leukaemia drug called Glivec rejected by the Indian Supreme Court. Novartis had been trying for six years to obtain the patent, but the court ruled that patent status requires and recognises clear innovation resulting in proven increased efficacy  rather than minimal adjustments to an existing product.

This ruling sends a strong message about the potential for patients in developing countries to access affordable medicine. First, it prevents large, international pharmaceutical companies from protecting much-needed medicines through patents which result in product exclusivity, lack of competition and the levying of a high sale price by the drug’s ‘owners’. Second, the court’s ruling indicates support for the manufacture of non-brand-name copies of the drug by generic companies in India (a major medical manufacturer serving many developing world countries). These can be sold at a much lower price to meet widescale medical need. For example, Glivec costs nearly thirty times as much, per patient, per year, as the generic version of the same drug manufactured in India.

As Avert, the international anti AIDS/HIV charity, explains:

A generic drug is an identical copy (bioequivalent) of a brand name (or proprietary) drug. Generics are exactly the same as their branded counterparts in dosage form, safety, strength, route of administration, quality, performance characteristics and intended use. The notable difference between the two is the price.

 While this week’s ruling concerns a leukaemia drug, its principle can be extended to treatments for HIV and AIDS medicines. India’s manufacture and export of affordable HIV medicines (and other generic drugs) has benefited millions of sufferers in the developing world, most notably to treat AIDS epidemics in Africa.

The competition amongst generic manufacturers, consciousness-raising among global health advocates and close collaboration with pharmaceutical companies have resulted in falling prices, which have put medicines – especially specific treatments for HIV and AIDS – into the reach of many millions more people in poorer regions.

At the heart of the issue in this particular ruling is patients’ right to affordable treatment. The right to be healed, where healing is available and has been proven effective, should not be denied to a sufferer because they are poor.

What is chilling, however, is Novartis’s response. In a TV interview after the ruling, the company’s vice chairman (and MD in India), Ranjit Shahani, hinted that the decision would have a negative impact on Novartis’s plans for investing in India, doing further research and development or introducing new drugs to India.

This is, effectively, a blackmail threat*: allow us to keep our vital drugs exclusive and expensive or we will freeze you out of the game completely, new research will grind to a halt, new medicine access (no matter how inaccessible, discriminatory and unaffordable) will cease altogether and millions will die.

The fact that large companies are willing to try and play tactical threat-games with people’s lives is disturbing and amoral. If international pharmaceutical corporations cared about people suffering major illnesses it would back the democratisation, universalisation and affordability of treatments and demonstrate through its actions that it values curing people more than making a profit, because human beings are more important than money.

Further reading:

-        Sarah Boseley has covered this particular case very clearly and thoroughly here in The Guardian

-        There’s a clear BBC new report with a very interesting analysis by Indian journalist Shilpa Kannan on the Glivec case.

-        The international AIDS/HIV charity Avert has comprehensively set out the basics when it comes to costing, manufacturing and supplying treatment and medication for sufferers.

-        Avert has also produced an interesting report on the history of, challenges to and ways forward for universal access to HIV/AIDS treatment, if you click here.

-        There are extremely thorough reports on the provision of AIDS/HIV medicines in the developing world, produced by the Interagency Coalition on AIDS and Development (ICAD). Click here and then click on the Our Work and Publications Tab.

…And, to add my feminist twist, there’s also a very pertinent feature on the link between HIV/AIDS and gender inequality:

Many of the social and economic barriers that stand in the way of effective HIV prevention, treatment, support and care for people living with HIV are the same barriers that impede access to comprehensive sexual and reproductive health programs and services. For instance, the circumstances that can lead to unintended pregnancies can also lead to infection with HIV and other STIs. Sex is the common denominator. In societies where cultural and gender norms tightly restrict the sexual and reproductive lives and choices of women and men, the risk for both unintended pregnancy and HIV infection is greatest.

Jennifer Kitts and Nicci Stein, ICAD

Bidisha is a 2013 Fellow for the International Reporting Project. She is reporting on issues of global health and development. 

* and one which is common in the rhetoric of many large companies – I don’t want to single out Novartis for blame in behaving like all its peers

Deadly fire: illuminating disadvantage and killing more people than malaria annually

At first, I didn’t take the problem seriously. I was contacted by a colleague who works with international charities, asking me if I knew about the dangers of fire. They were obvious, I thought. But then she told me about the issue of smoke inhalation from poorly ventilated homes, writing, “the latter is a very under-reported issue that has a big impact both on women's health and also on women's independence. Women are forced to stay in their homes all day watching the fire - breathing in smoke and trapped at home unable to go out, go to school, go out to work etc. It's so important to make the connections between poverty, health and the lack of women's economic independence. All too often those links aren't made and it is as though the problems just spring from no where or are inevitable when in fact they are almost always connected to gender inequality. ”

Image (c) Practical Action

As I explored the campaign, Killer in the Kitchen, I began to see how this issue, which at first seemed simple, was actually an original way of seeing how a health issue reflects various underlying and interrelated challenges to do with poverty, health, development and gendered inequality. This issue is where a matrix of social, financial and economic values comes together to create and maintain inequality and disadvantage.

The health risks of smoke inhalation affect women disproportionate because of their exploited, subordinated and labour-exploited status. There is the expectation that food preparation, food serving and all additional domestic labour including cleaning and all childcare are a woman’s duty. There is the expectation that this labour, despite its hard, perpetual, repetitive and unrelenting requirements, is not worth payment or respect. There is the fact that the sheer amount of free labour demanded of women is so great that their ‘duties’ prevent them from studying or self-teaching or pursuing other work outside the house. There is the wider issue of absence of resources, which mean that alternative means of heating and cooking, different methods of building and ventilation and alternative technologies cannot be employed as there is no money to pay for them.

• Each year the smoke from indoor cooking fires kills more people than malaria. Almost 2 million lives lost, needlessly.
• Half the deaths from pneumonia of children under five are attributed to indoor air pollution.
• Indoor air pollution is the biggest child killer in Nepal. Click here for more information.
• Over 1 million people die each year from Chronic Obstructive Pulmonary Disease (COPD), again attributed to exposure to indoor air pollution 

Practical Action, Killer in the Kitchen campaign. 

The figures, provided by the World Health Organisation, who have produced an extensive report, are shocking. More than three billion people - half the world's population, and its poorest – use simple stoves or three-stone fires to burn fuels such as wood, crop waste, dung and coal for cooking, boiling water and heating. Every year, nearly two million people die, usually from respiratory infections, as a result of inhaling the pollutants in the smoke produced when burning the lowest grades of fuel. Thus those who are already disadvantaged by poverty and therefore have the least access to the ‘clean’ energy provided by higher grade fuel are at risk from the by-products of the lower grade fuel they must use. The majority of victims are women and children under five.

Practical Action has created film footage showing model Gisele Bündchen’s visit to explore the issue in western Kenya and consider the use of waste as a resource – click here to see more. Looking at the wider geographical picture there are certain general actions that can be taken, with the proper investment and support, to implement the use of sustainable and clean energy and develop appropriate and inexpensive cooking and heating technologies that liberate their users (mainly women) both from the labour duties required and the health risks incurred. Both these factors have the potential to challenge what is expected of women, create time in women’s days, lift families out of ‘energy poverty’ and transform women’s own physical health and mental potential and those of their children. 

The methods suggested for combating the problem are cheap and relatively easy: the use of better stoves which reduce the amount of firewood used in a traditional fire by two thirds; sheet metal hoods which channel smoke out of the house and reduce indoor smoke levels by up to 80%; fireless cookers which use stored heat to cook food over a long period of time, saving fuel and reducing smoke.

If we look at case studies in Nepal, Kenya and Sudan we see that these simple measures have had extremely positive results. Happily, there is some evidence of solid political will behind the issue: the Nepali government aims to make all homes in Nepal smoke-free by 2017 and the Global Alliance for Clean Cookstoves has pledged to provide 100 million clean-burning stoves to settlements in rural Africa, Asia and South America by 2020.

Bidisha is a 2013 Fellow for the International Reporting Project. She is reporting on issues of global health and development. 

Vaccines and immunisation: don’t leave a fifth of the world’s children behind

“The hospitals are filled with children with vaccine preventable diseases.”

Johanna Sekennes, Médecins Sans Frontières, Head of Mission, Mali

The rain’s falling thickly onto the roads in rural eastern Mali, preventing cars from passing and making travel by foot virtually impossible. Yet – as a beautifully shot yet hard-hitting new short film, A Preventable Fate, by Venetia Dearden, makes clear – the rainy season does not mean a halt to all industry.  Instead, it coincides with the farming season. Hard-working women, many with children on their backs, labour in the fields to ensure a good crop and a good livelihood. Their responsibilities to the land, to their families and to the sustainability of their agricultural practices, combined with environmental and other external factors, are just some of the complex obstacles standing in the way of them accessing adequate healthcare for themselves and their children. In the first year of their lives, children must receive vaccines five separate times – a tough ask for women given the distance that sometimes needs to be covered, the cost or difficulty of the journey and the other labour-demands a woman is subject to for survival.

The images of rural life in Dearden’s film have a liveliness, community spirit and wholesomeness which belie the tougher realities of under-resourcing in the area and generally in rural and economically disadvantaged regions across the developing world. A Preventable Fate is part of a series of six films around the theme of Fatal Neglect, produced by Doctors Without Borders to highlight the obstacles faced by millions of people worldwide in accessing quality healthcare. The series also includes a study of treatment-resistant TB and three neglected tropical diseases.

In looking at the issue of vaccinations and immunisation in Mali we see that the women working so hard in the fields do not have a day to spare to take their children to be vaccinated – a journey which is difficult even by car, let alone on foot. If a woman happens to live in a village where there is no local vaccine campaign, she may have to go even further away. A Preventable Fate features a woman explaining to a doctor at a vaccine project that she has two children and came to visit the project by bike, “and I got a flat tyre. So I had to walk. It’s very difficult.” It is too much to demand of a mother or other caregiver that they take each child to a vaccine campaign outpost at least five times within that child’s first year, when shortages of vaccines may mean that repeat visits are necessary, and that trips are made without knowing whether the vaccines will be available. For those children who receive perhaps two or three of their five shots in the first year, few workable systems are in place to record, trace and make up for the vaccines they have missed when they are a little older.

Photograph (c) Medecins Sans Frontieres

 In addition to the challenges of time, distance and work neglected are problems with establishing vaccination campaigns themselves, in terms of personnel alongside the stocking, transportation, safety and sustainability of medicines. More health professionals who can administer the vaccines are needed; the ideal thing would be to have locally-trained, locally active nurses not just providing vaccines by operating as a reliable and stable way of raising awareness amongst communities. The vaccines must also be transported correctly; a challenge when considering that many require something called a ‘cold chain’, that is refrigeration at a specific temperature otherwise they become invalid. This requires the useage and maintenance of refrigerators and icepacks to store and transport vaccines.

Thus the seemingly simple question of providing vaccines becomes complicated in areas where electricity provision and consequently refrigeration is sporadic, healthcare professionals are scarce, distances between services and users are long, natural temperatures are high and road quality is variable. What is required is the development of vaccines which are easier to deliver and easier to administer to children.

In May 2012 the 65^th World Health Assembly designed a Global Vaccines Action Plan to kickstart a well-funded Decade of Vaccines project working towards global vaccination. However, as the Fatal Neglect project makes clear, all major health initiatives must be sensitive to the particular challenges and particular contexts in which healthcare initiatives are established and provided – with a particular focus on those who are being left out due to issues to pricing, the adaptation of medicines and logistical barriers. MSF’s report The Right Shot: Extending the Reach of Affordable and Adapted Vaccines explains some of these issues in detail. They suggest that instead of developing countless (and expensive) new vaccines such as those against pneumococcal disease and rotavirus, the basics of existing routine vaccine systems should be perfected and adapted to theenvironments in which they will be used so that they can benefit the most children, especially in remote, rural, civically fragile/unstable or economically disadvantaged areas. In India’s state of Bihar, for example, 60% of babies are not fully vaccinated. The MSF points out that failure to perfect the access, ease, stability and application of the most basic vaccine programmes have resulted in recent outbreaks of preventable diseases, like the 2010 measles outbreak in 28 African countries. In the Democratic Republic of Congo (DRC) alone, 100,000 cases were reported between January 2011 and October 2011. Although there are many factors affecting the pricing of vaccines, a cynical reading could conclude that the basic, inexpensive vaccines programmes are not being perfected because there is little financial incentive for pharmaceutical companies to tailor their vaccines to help those populations who have little purchasing clout as consumers themselves.

The message on vaccines and immunisations is clear, but tough to swallow. At the moment, 20% of all babies born in the world – that is 22 million children born last year alone - are not receiving protection against basic yet potentially fatal diseases such as measles, meningitis, diphtheria and yellow fever.  Underpinning the moral argument that all children born worldwide deserve the basic human right to life, health, protection and the best start in life, since medicine should not be a luxury is the transformative future effect we can envisage on already-pressurised global healthcare initiatives. Universal vaccination would drastically reduce pressure on hospitals, child mortality rates and sickness rates.  Vaccines must be researched,developed, produced and delivered in such a way that they are easier to use, easier to administer, more temperature-stable, easier to transport, adapted to developing countries’ environmental factors and also the medical factors – that is, the specific strains of the diseases found in the countries in which they will be used. Single dose vaccines which do not required difficult multiple visits; vaccines which are administered orally rather than by injected; well-trained, numerous and either highly mobile or strongly rooted and dedicated local healthcare professionals; vaccines which are affordable to all countries in the long run and not just those which rely on finite donor support through the Global Alliance for Vaccines and Immunisation (GAVI)  to pay for them; and vaccines which do not degrade in variable temperatures would be just some of the ways forward, or more that 22 million children will pay the price.

Photo (c) Medecins San Frontieres

Bidisha is a 2013 Fellow for the International Reporting Project. She is reporting on issues of global health and development. 

"Nothing for us, without us." Women rise in Afghanistan, Malawi, Nepal, Zambia, Zimbabwe and Ghana.

In February Womankind Worldwide welcomed their partner women’s rights activists from Africa and Asia to London to share their experiences and expertise of women’s leadership and political participation. Further images from the day, all taken by Abi Moore, can be viewed at the bottom of this article.

At the Emmeline Pankhurst statue with Seema Malhotra MP

From countries as diverse as Afghanistan, Ghana, Nepal and Zimbabwe, participants faced a similar challenge – how to overcome the exclusion of women from political and public life.  Despite their different contexts, cultures and political systems, the women highlighted some common problems and common solutions.

Women’s voices must be heard from every corner and at every level. Women are not a homogenous group, and their participation in politics must reflect their diversity.  Durga Sob, founder of the Feminist Dalit Organisation of Nepal said, 

“Dalit women are doubly discriminated against in political parties – Dalit forums are run by Dalit men, and women’s wings of parties are run by ‘high-caste’ women."  

Young women, disabled women, women from ethnic and religious minorities often face multiple barriers to accessing decision-making spaces, and they must be supported.

The women were united in their commitment to focusing on local as well as national politics. Local level is where many of the decisions affecting women’s daily lives are made, and as Wangechi Wachira from Kenya’s Centre for Rights and Awareness said, 

“to be a leader, it starts at family level, and then changes happen at community level.”

 Civil society, and in particular women’s right organisations, provide fertile training ground for women’s leadership, and enable women’s voices to be heard.  Maryam Rahmani, of Afghan Women’s Resource Centre, said,  

“we need to find space for women to speak about the issues that affect them, even when it’s difficult." 

In Afghanistan, where 87% of women have experienced some form of violence, and women activists and politicians are routinely threatened, attacked and killed, this work is vital and dangerous.

Women’s rights organisations help to build women’s confidence and skills, create opportunities and access to political spheres. When women do get into positions of influence and power they are supported to negotiate corridors of power, build networks, and advance women's rights.

The activists were unanimous in the need for affirmative action to level the playing field between women and men.  Whether through political parties, reserved seats or quota systems, the only countries that have made significant progress are those that have taken specific measures.  And compared to those countries, the UK does not perform well.  In Afghanistan 28% of MPs are women, in Rwanda it’s 56% and Mozambique 43%, compared to the UK’s paltry 22%. 

The voices of women from all walks of life need to be heard in all places of power. From community forums to the halls of national parliaments, and on the international stage, as Fanny Chirisa from Zimbabwe’s Women in Politics Support Unit said, 

“Nothing for us, without us."

*****

The organisations attending were as follows:

• Afghanistan: Afghan Women Resource Centre (AWRC)

The Afghan Women Resource Centre provides practical education to girls and women who were forbidden to learn under the Taliban.Their programmes allow women to learn in a safe environment, with a focus on vocational subjects including journalism, business skills and tailoring, in order for women to be able to earn an income and live independently. They also teach literacy, civil & political rights, and women & family law.

Attending: Maryam Rahmani, Country Representative. Maryam got involved with AWRC by doing short management courses when she was at school in Peshawar, Pakistan. In late 2002 her family came back to Afghanistan, where AWRC had opened a sub-office, where she began working. In the meantime Maryam passed her exams and joined Kabul University, eventually graduating with an economics degree in 2007. The
university faculty board wanted to recruit Maryam as assistant to a professor but only on the condition that she left AWRC. Maryam refused as she wanted to continue helping women.

- Case study 1: Campaign: Don't Silence Afghan Women

- Case study 2:  Take Action to Help Afghan Women

• Malawi: National Women’s Lobby Group (NAWOLG)

Potential female political candidates in Malawi often struggle with lack of funds, social pressures to stay at home and patriarchal political organisations. NAWOLG’s goal is to get more women to become involved in the democratic process as voters and representatives. It has a team of professionals specialising in gender, human rights and civic education issues, who help provide training and support to women inside and outside of politics.

Partners attending: Faustace Chirwa, Founder/Executive Director. A gender and women’s rights activist for 17 years, Faustace continues to promote women’s participation in the socio-economic development of Malawi and in political decision making.

And Atupele Chirwa, Acting Executive Director. Atupele started off volunteering with NAWOLG in 2003 and is now acting Executive Director. She focuses on sexual reproductive health and rights issues of young people in Malawi.

• Nepal: Feminist Dalit Organization (FEDO)

The Feminist Dalit Organization was founded in 1994 by a group of Dalit (low caste) women aiming to fight for their rights and overturn caste and gender discrimination which causes women and especially Dalit women to be treated as second class citizens facing very high levels of sexual and domestic violence. FEDO educates women on their rights, offers counselling and organises mass protests and community events to raise awareness.

Partner attending: Durga Sob - FEDO. Durga Sob is a Dalit woman who founded the Feminist Dalit Organisation in 1994 to combat caste and gender-based discrimination in Nepal. Durga is renowned as a passionate feminist and activist in defending the rights of Dalit women in Nepal. She says,

“There used to be no Dalit women in positions of power. Now 25 Dalit women have been
elected as members of the Constituent Assembly and this is one my happiest achievements”.

- Case study: Pabitra's Story

- Example of the kind of context they’re working in:  Women Human Rights Defenders Beaten and Detained

• Zambia: National Women’s Lobby (ZNWL)

ZNWL aims to promote the representation and participation of women at all levels of decision-making through lobbying, advocacy and capacity-building. It provides education, runs community forums, provides leadership courses in schools to boys and girls through their innovative ‘Girl’s Leadership Clubs’, monitors elections and provides support to women involved in politics, for example through Women’s Radio Clubs, supporting isolated rural women to gather to listen to news about politics and current affairs and discuss together so that they’re better equipped to take part in the democratic process.

Partners attending: Juliet Kaira Chibuta, Executive Director. Juliet is a development specialist and a journalist by trade. She worked for national print media organizations including the Zambia Daily Mail and National Mirror where she held various positions including editor. Ms Chibuta has also sat on various boards of media and women’s organisations.

And Beauty Katebe, National Chairperson. Beauty is a human resource expert and works in Zambia’s Ministry of Health. She has vast experience in women and youth issues, democratic processes, capacity building of women, governance and elections issues. She is the current National Women Council Chairperson of the Agriculture, Technical and Professional Union of Zambia.

- Example project More Than Education for Girls

• Zimbabwe: Women in Politics Support Unit (WiPSU)

The Women in Politics Support Unit (WIPSU) provides support to women in politics in Zimbabwe to help increase their participation and influence. It does this by providing leadership and election training for candidates; educates women MPs and councillors about their roles, connecting them with female constituents; organises community forums; and lobbies political parties to implement gender quotas.

Partner attending: Fanny Chirisa, Director. Born in Mutare, Fanny has worked with The Federation of African Women’s Clubs, The Voluntary Organizations in Community Enterprise, Red Banner, Zimbabwe Women’s Resource Center & Network and WiPSU. During the outreach process of the current Zimbabwean Constitutional Reform Process, Fanny was invited to be team leader representing civil society.
They led teams of reporters capturing the views of citizens across the country.

- Case study: Not Service But Power

• Ghana: Women in Law and Development in Africa (WiLDAF)

Since its inception in Harare, Zimbabwe, in 1990, the network has grown to encompass 31 countries, 500 organisations and more than 1,200 individual members. At the national and international levels, the WiLDAF network lobbies for laws that promote women's rights. In Ghana, WiLDAF offers free legal counselling as well as training in legal literacy.

Partners attending: Bernice Sam, Executive Director (Ghana branch). Bernice Sam is a lawyer and human rights activist. She spearheads the campaign for the participation of vulnerable groups in democratic processes including organising women’s dialogues with presidential candidates. She also led the struggle for the protection of the rights of people in non-formalised relationships. Bernice has written and co-authored books on HIV/AIDS, violence against women and the property rights of women.

And Frank Bodza, Programme Manager for Governance (Ghana). Frank has more than nine years’ experience in both local and national governance; having worked with an MP for four years prior to joining WiLDAF in 2005. He is a gender and human rights activist who had carried out numerous public education programmes on women’s rights issues. He is experienced in capacity-building, mobilization, networking and coalition-building and was part of groups that observed the December 2012 general elections in Ghana. He is married with two children.

Richard Sam, Programme Assistant for Governance (Ghana). Richard did his national service with the Ministry of Local Government and Rural Development for one and half years before joining WiLDAF in 2009. He is a volunteer from WiLDAF Ghana on the Coalition of Domestic Elections Observers (CODEO) and the Civic Forum Initiative. Both groups have observed various elections including the December 2012 general elections in Ghana.

- Case study:  Ghana Elections: Time for Women to Rise, Not Fall

- Context can be found here.

• Ghana: The Gender Studies and Human Rights Documentation Centre (GSHRDC)

The Gender Studies and Human Rights Documentation Centre works to promote and protect women’s rights, running a number of projects in rural Ghana working to end violence against women and reduce women’s vulnerability to HIV infection.

Partners attending: Dorcas Coker-Appiah, Executive Director. Dorcas Coker-Appiah is a lawyer by profession and a feminist. She is a women’s rights activist in Ghana and a member of a number of women’s rights organisations. Dorcas has a lot of international experience, having served two terms as a member of the United Nations Committee on the Elimination of Discrimination against Women.

- On work to end the practice of ‘widow inheritance’ read this piece here.

• Kenya: Center for Rights Education and Awareness (CREAW)

CREAW’s mission is to transform Kenyan society through the promotion and expansion of women’s human rights, rule of law and social justice. They provide legal aid and health services to thousands of female survivors of rape and domestic violence, produce informative radio shows and give training and support to community organisations.

Partner attending: Wangechi Wachira, Executive Director. Wangechi Wachira has more than 10 years of experience in senior management. She has experience in lobbying and advocacy, gender integration and inclusion, human rights and development issues.

- More info here on the Center for Rights Education and Awareness

Dorcas Coker Appiah 

Atupele Chirwa

Fanny Chirisa

Frank Bodza

Faustace Chirwa

Maryam Rahmani

Wangechi Wachira

A special post (c) Sarah Jackson at Womankind Worldwide with enormous gratitude and admiration

Bidisha is a 2013 Fellow for the International Reporting Project. She is reporting on issues of global health and development.