The Cut: daughters, elders and local health workers speak out about female genital mutilation in Western Kenya

If you’re interested in the issue of female genital mutilation you might also want to read Cutting Us Down To Size: Working To End Female Genital Mutilation

An excellent film called The Cut by Beryl Magoko – not to be confused with the equally impressive recent British documentary The Cruel Cut – received its UK premiere at the 2013 London Feminist Film Festival and was awarded the Best Feature prize there a couple of weeks ago. Filmed in Uganda and Kenya, The Cut is a careful and intelligent documentary which enables diverse members of the featured small, rural communities where FGM is practised to speak about its meaning and history, while maintaining a clear but unpressing authorial sympathy towards the girls who undergo it. Despite comprising interviews and talking heads as well as some close documentary observation, ultimately the body language and silent reactions of the young women speak the loudest. The Cut has already won Best East African Film at the Kenya International Film Festival as well as many other plaudits.

The Cut establishes female genital mutilation as a social practice with a history so longstanding that even its apologists cannot explain it adequately. Both those who oppose and those who defend it mention the pressure girls are under to have it done.

Watching some of the older male apologists for FGM is a chilling experience. They display an odd, chippy defensiveness at being challenged and their comments are shot through with contempt for the (as they insinuate) wilfulness and irrational bloody-mindedness of women. One man says, “If a girl wants she will be circumcised. She runs away and goes for circumcision.” What we see in the film, instead, is the establishment of a haven for countless girls who have gone there to avoid being cut. Despite the existence of this refuge some parents, of both sexes, take the girls away against their will to be cut.

“They make a small mark on the knee,” says one man dismissively. I do not think he is lying outright, although he is speaking with heavy euphemism; I think he genuinely does not quite know exactly what is involved. As the film goes on to show, FGM is a female-perpetrated community act in the moment, although as a cultural practice it is endorsed by both sexes and it is ultimately approved, instigated and organised by men with social power. As one woman warns, “the sons of council elders inherit the right to organise circumcision.” Despite FGM being presented by detractors and apologists alike as something done to women by other women, often those women who are closest to them, its survival as a tradition can only be ended officially by council sons of council fathers, not mothers, wives or daughters.

Another man in the early minutes of the film insists,  “We don’t force them, nobody forces them.” But force is not always physical and momentary. Peer pressure, the weight of long tradition, the heat of expectation, the actions of the majority and the social cost of resisting the practice constitute different types force in themselves – forces which are sometimes harder to resist than the application of physical power. One adult woman explains how an uncircumcised girl will be ostracised and describes being shouted at, verbally abused, mistreated and cold-shouldered at her school, where 98% of the girls had been circumcised. The girls are caught between forces which are at once oppressive of their own instincts and free will and yet socially inclusive, communally approved, deemed to bring order and harmony to all. Another woman says carefully, “a good child has to obey the parents.” Her personal pain and regret are subsumed into a wider vision of what would please the people beyond herself.

One of the many subtle arguments The Cut makes is that female genital mutilation is related to poverty and education. One man says that when a girl has been cut “she can get married, give birth and handle a family,” even though it is obvious that the girls in the film are still virtually children. The under-education (in terms of both social values and academic status) of the parents creates a cycle in which the under-education, physical brutalisation, sexual and labour exploitation and social disempowerment of girls is perpetuated. The cutting of a girl is presented as a sign of her initiation into womanhood and therefore her readiness to marry and procreate. Anti-FGM speakers in the film rail against “illiterate parents” who do not see the value of education for a girl; they circumcise and marry off daughters who might have wanted to continue with their studies.  

However, The Cut also conveys how strong the anti-FGM movement is, with leadership coming from both sexes. Indeed the defensiveness and vehemence of the apologists, virtually all of whom are of an older generation, shows that the drive to end the practice is gaining ground. We see groups of very little girls chanting and holding up signs reading, “Don’t circumcise me! Don’t hurt me!” and “When you circumcise a girl, you destroy her life.” Male preachers urge, “Leave this outdated cultural practice.” Handsome men of marrying age have a pretty persuasive line that makes me smile: they say that FGM excises “the sweetest and most delightful part of a woman.” I always thought that my most delightful parts were my brain and my heart, but there you go. Another man says he doesn’t want to marry a woman who has undergone  FGM because “I want her to be sexually satisfied.” Another man tells a crowd, “You can tell the difference between [happy] wives who have not had it done, and [unhappy] wives who have.” 

The Cut is expertly structured, with a sense of foreboding that increases with every testimony. The women who have been cut, some of them looking barely ten years old, seem bashful, not angry, when expressing their pain and disgust.  “It was very painful. I will never forget,” says one, her eyes sliding as she remembers. Another represses a shudder as she describes the way she was mutilated: “They would use [the razor] to cut everything [around the genital area].”

The Cut’s masterstroke – to use exactly the wrong word – is the access Beryl Magoko has gained to the circumcision rituals themselves. These happen for both sexes. The boys are circumcised in one area and we see them surrounded by countless male friends, neighbours and relatives, whooping, hopping, singing and celebrating. Then we see them standing with their willies hanging out, all looking like skinny kids. Each one clenches his jaw and keeps his chin up, lips firm, eyeing the boys on either side, full of determination not to show any pain. Despite that, quite clearly, it hurts a hell of a lot. When the circumcision is done the boys look dazed and miserable, oblivious to the partying around them. They’re escorted back home by all their friends, bleary eyed and unsteady, silent, as though all they want to do is lie down in a darkened room.

The girls are in a different area. Just like the boys, they are surrounded by their same-sex relatives and supporters. The atmosphere is wonderful, full of celebration, connection and encouragement. I can well understand the sense of rejection and chagrin, even confusion and blame, that a community would feel and then bring vengefully to bear on a girl who refused to undergo FGM. And I could well understand the conflicted feelings of any girl who does not want to be cut yet who is naturally drawn – as anyone would be – to a celebratory event in which everyone participates and supports each other. This is not about girls being too weak to say no, but about the strength of a culture in persuading, muffling, denying or overriding that no. Additionally, The Cut makes it painfully clear that the girls who submit to FGM do not do so because they are passive but because they are innocent. The reality of what exactly will be done to them is concealed from them until it’s too late. 

At the FGM ceremony there is an atmosphere of frenzy, an undercurrent of brisk determination to see it through despite anyone's hesitation or aversion and a core of dark zeal, as at any rite where blood is to be shed. Amidst the celebrations of the brightly dressed older women around them – a celebration in whose rhythms and music I can’t help but hear the refrain cycle-of-abuse, cycle-of-abuse – the girls themselves are subdued. They become increasingly and instinctively nervous as they are jostled to stand in a line and then pushed down to sit on the ground, then lie back when their time comes. We see money changing hands as women buy pairs of surgical gloves from a vendor.

The innocence of the girls is such that one casually helps her mother get a fresh surgical blade out of its sterile packet. The girls are forced back and told to relax with their legs bent and naturally apart. Fear spreads from girl to girl to girl. The older women grow carping, bossy and a little physically rough, relishing their one moment of power. They bully the girls and egg each other on. One of them holds the razor and cuts a girl. It’s unwatchable.

Afterwards, there is silence. The girls look sick, queasy with pain. Their faces are rubbery with shock and, for some, tears pour thickly down their cheeks. Their eyes are dead. The girls are unable to sit up. They are clearly, obviously, visibly traumatised, in shock. A sizzle of glee passes through the older women who throng, dance, gather. They look triumphant, like bullies who’ve gained a point.

A health worker filmed in her clinic says, “after FGM you can have death from bleeding out. You can catch an infection. There can be a cross-infection.”

A male apologist insists, “girls don’t bleed and are not cut painfully.” His comment is not just motivated by an arrogant dismissal of female pain but - as echoed by many of the speakers - a suspicion of health workers. Multiple commentators hint that “the negative effects come from doctors” who they say are misleading people about the risks of FGM despite having to deal with the consequences when things go wrong. There is, overall, a resistance to the kind of change that the clinic symbolises: a national, standardised and networked healthcare system relying on medicalised, non-naturopathic treatments. Something very simple lies at the heart of all this: resistance to change and fear of the loss of defining and unifying rites. “It may end gradually. We can’t stop abruptly. We say it’s an initiation and we believe it’s good for us,” says one man. Another person repeats fervently, “It will not end” because “culture doesn’t end. Ever.”

The girls are escorted home. Their faces have been daubed in talcum powder to mark them as ‘initiated’. With colourful hats and parasols held over their heads they look like little ghost emperors. The pressure of the bodies around them and the willpower of the crowd seem to be the only things holding them up. The people are singing, dancing and jogging alongside the girls.

A still from The Cut by Beryl Magoko

It’s a terrible journey back. The girls pass in and out of consciousness, crying, staggering, fainting, sweating and collapsing, barely able to walk. Their eyeballs roll, their necks go floppy. Blood runs down their legs. They are shaken firmly, scolded and harangued. There is no tenderness whatsoever. Never before has it been so clear that FGM – the entire day, not just the moment of cutting – is not about celebrating the start of womanhood but about forcing female obedience, beginning a trauma which makes girls mentally vulnerable and therefore susceptible to further control and abuse, women bullying girls and the deliberate debilitation and weakening of strong, healthy female flesh. FGM is a socially sanctioned brutalisation process justified as a rite so ancient that nobody can remember its purpose, thereby leaving it usefully open to conventional patriarchal justifications.

A woman describes the “excruciating pain” of female genital mutilation.

Another woman says, “I regretted having gone there – but it was too late.” It was done.

We see the girls being taken home, glassy eyed. They are so traumatised physically and mentally that they’re unable to speak. They are encouraged to lie down. They can barely manoeuvre themselves. We see one mother trying to get her daughter to eat a biscuit. The daughter is unresponsive. She is too weak to chew.

In the aftermath there are countless physical problems, in addition to the mental trauma. It is difficult to urinate and it can take up to three weeks to walk properly. One woman says she “can’t even bathe alone. You need to be held.” Much older women describe how they “staggered” and “couldn’t sleep or walk for ten days with the pain.”

The wound must be left to heal in a certain way. If a girl sleeps with her legs closed the wound is forcibly re-opened.

“It’s so painful that I can’t even explain,” says a woman.

“It is like taking a hot nail and putting it on the wound,” says another woman.

A health worker explains the biologically necessity of the clitoris, which helps the vagina to stretch during childbirth. But FGM can remove the clitoris, leaving scar tissue: “Scar tissue doesn’t expand, which leads to tears, which obstruct labour. This leads to tears upwards and also down to the anus in childbirth. So a woman can develop a third degree tear – vagina to anus.” It’s not the word ‘tear’ that gets me about that quote, it’s the phrase ‘third degree’. Because I’m guessing there aren’t a whole load of degrees to get though and third is pretty much the worst. From this, a woman can develop a fistula, which means that she passes faeces through the vagina, the barrier separating the vagina and anus having been ripped. 

Another health worker adds, “I feel [FGM] should stop. It’s just humiliating. If they want to do it let them do it on adults who can sign their own consent form.” For the villagers shown in The Cut, the power to end FGM officially and decisively is in the hands of the new generation of men, the sons of the council elders.

A woman who underwent female genital mutilation says, “If I could stop it, it would have ended.”

Further reading:

·           An interview with Beryl Magoko about The Cut and the issue of female genital mutilation.

·           The official press pack for The Cut, giving full credits and further details of the film’s history and making, can be accessed here.

·           Read Beryl Magoko’s directors’ notes about the challenges she faced when filming.

·           Listen to award-winning reporter Juliet Spare’s feature on female genital mutilation for Voice of Russia

Bidisha is a 2013 Fellow of the International Reporting Project, covering global health and development.

Taking action on the global health worker crisis

A couple of weeks ago I covered the importance of a well-trained, well-paid and well-respected human resources system in providing free universal healthcare globally. I analysed the challenges of doing so and examined some of the factors which can enable or inhibit good practice. Since then I’ve become aware of a new drive, flagged up by Health Poverty Action, which highlights the UK’s responsibility when it comes to global human resources in the field of health. It emphasises a developmental imbalance - with serious consequences for developing countries - created by the Western exploitation of global health worker labour.

Health Poverty Action has identified more than fifty countries, mainly in Africa and South Asia, which suffer from a “critical shortage of health personnel” while simultaneously carrying “a large part of the global burden of disease.” At the same time the increased necessity of long term care for ageing populations in European countries is creating strong demand for health workers, fuelling the migration of health workers to Europe from developing countries in today’s heavily globalised labour market.

Image of health worker in clinic in Tsumkwe in Namibia (c) Health Poverty Action

Health Poverty Action has been calling for the UK to “compensate developing countries for its role in the global health worker crisis.” There is a cached copy of the call here; I'm not sure what has happened to the plan to get supporters to write to UK MPs. The charity points to the shortage of health workers in developing countries and the UK's strong record of employing health workers who are originally from developing countries and migrate to the UK to work. HPA is not challenging people’s entitlement to move for work, to earn, to study and to create better lives, but instead seek simply to raise awareness of the consequences of the health worker shortage in developing countries. The responsibility for this must be on world governments engaged in large scale health infrastructure and planning. The shortage of health workers in developing countries results not only in poorer treatment there but in a variety of deficits which weaken the entire health system in the long term, from the under-staffing and under-maintenance of hospitals, clinics and rural health stations to poorer quality and less up to date training and education, the under-provision of medical equipment, the reduced chance of future investment when a future workforce cannot be relied upon and much more.

The charity adds,

It is estimated that 1 billion people [virtually all in developing countries] will never see a health worker, putting them at risk of dying from easily preventable diseases, from childbirth and basic health conditions.

The report Aid in Reverse challenges the UK government to play a conscientious and responsible role in ending the global health worker crisis, which Health Poverty Action labels a developing world “brain drain.” They suggest that in the UK the Departments of Health and International Development could work together on two complementary issues: first, treating the roots of the UK’s own shortage of health workers through better planning, training and education; second, giving something back to the developing countries whose health infrastructures are being weakened through lack – with severe ramifications for those nations’ own long term development – while they contribute so much to developed nations’ healthcare systems.

The challenge to developed nations who use the labour of talented health workers from developing countries to ensure their own citizens’ wellbeing is part of a pan-European initiative aiming to create a sustainable global health workforce. One of the main directives of the project is the implementation of a World Health Organisation Global Code of Practice on the International Recruitment of Health Personnel. The project’s tagline runs,

‘Healthworkers for all and all for health workers.’

Bidisha is a Fellow of the 2013 International Reporting Project, covering global health and development.

"Every woman has basic human rights" The Circles empowering women for health, development, education and freedom from violence

Earlier this year I chaired a panel with Joan Smith, Baroness Helena Kennedy and the novelist Kishwar Desai. We were discussing male sexual violence in India, following the worldwide protests about the rape, torture and murder of a young woman in Delhi. The event, at The Nehru Centre in London, was held to launch Desai's latest novel Sea of Innocence, which tackles the same issue and also provides shocking details of the Delhi case which hadn't previously been revealed in the media. In its ability to combine a strong heroine with a thrilling plot and urgent contemporary issues, Sea of Innocence follows on from Desai's previous novel The Origins of Love, which looked at the Indian international surrogacy trade.

The conversation during the Sea of Innocence launch event was wideranging. We looked at all aspects of global rape culture, which transcends colour, religion, class, language, country, culture and hemisphere: the blaming of victims, the excusal of perpetrators, the prejudice against survivors of sexual violence, the silencing and abusing of survivors who speak out, extreme and perverse leniency towards perpetrators even when they are convicted. Male sexual violence, which is endemic, reflects, partially creates and also reinforces women's inequality, disempowerment and subjugation. This disempowerment is obvious in every area: in the discrimination against us in the workplace; in the exploitation of our labour, which is unpaid, under-paid, under-valued and over-consumed; in the denial of our rights over our own bodies; in the casual and constant judging, slandering, undermining and defamation which constitutes the majority of all comments made to and about women; in the way we are represented in mainstream culture, images, advertising and the media as silent pieces of nice-looking meat, pathetic and useless idiots or bitter, petty, malicious schemers; and in the strong resistance against female education, landholding, powerful visibility, money-making, public involvement, mobility in public spaces (which is delimited by harassment and threat), enfranchisement, leadership, influence, direction and presence. Writing specifically on rape culture, structural misogyny and gender inequality in India, there is a brilliant analysis by Tehelka Media which I urge everyone to read.

As UNIFEM states, "One woman in three will be raped, beaten, coerced into sex or otherwise abused in her lifetime." Male violence against women is so common that it has been described by the World Health Organisation as being "of epidemic proportions." Read the major, multi-national WHO study into domestic violence and see why they identify it as "a major public health and human rights problem throughout the world."

After the Sea of Innocence panel discussion I was approached by an impressive woman, Santosh Bhanot, who told me that she was involved in a project called The Circle, in affiliation with Oxfam. The Circle aims to address some of the fundamental issues and abuses which keep women worldwide in a state of disempowerment and inhibit our equality and our access to justice, rights and autonomy. Another underlying goal is to lift women out of poverty through gender empowerment.

The issue of poverty, often spoken of in general terms, is starkly gendered. According to Oxfam,

Of the 1.3 billion people living in extreme poverty worldwide, more than two thirds are women and girls.

Women and girls are the most disadvantaged of the disadvantaged, the most abused of the abused and the most exploited of the exploited. This has not arisen by some kind of unfortunate, fated magic but directly through the actions of patriarchal systems and many individual but misogynistically and patriarchally like-minded perpetrators, users and exploiters. When we defy all silencing and stigma to speak about what we have undergone we suffer the further grotesque abuse of being blamed for men's abuse of us, told that we deserve it, told that we brought it on ourselves by our own behaviour or told that we are lying out of malice to hurt men. We are then punished further by being slandered, marginalised or ostracised.

As Everjoice Win from ActionAid International, South Africa, states in a report about how helping women and girls is the key to ending poverty,

We believe that women are vulnerable and more impoverished compared to men because they have been systematically made vulnerable by years of violence, patriarchal power and control, as well as decades of inequitable laws and policies deliberately designed to put them in this position.

The Circle was founded in 2008 by Annie Lennox with the aim of connecting high profile, culturally influential women of expertise in various areas. A network of Circles will raise consciousness and money (here's the catch: money for Oxfam) to spend on a range of grassroots projects tackling everything from poverty to education to maternal health. They will also work "to reduce all forms of violence towards women, by helping to change attitudes."

The idea is that the various Circles support specific projects of interest but are all part of the wider Circle ethos of women helping women to change the world for everyone. A group called The Lawyers' Circle supports women's legal rights in Africa; The Music Circle raises money to protect women in the Democratic Republic of Congo; The Oxford Circle is looking at improving health and education in Niger and hopes to engage Oxford University and local city businesses in supporting this aim.

So far, significant money has been raised for a broad range of change-making initiatives. In Zambia the Circle project, working with Oxfam, is helping community schools. These are volunteer-run initiatives which provide vital education for one million Zambian children. However, those involved require more training and resources; the Circle's work in this area benefits 18,000 students in 25 schools and strongly supports the education of girls.

In Pakistan the We Can project is a grassroots initiative aiming to reach 800,000 people in combating "endemic" male violence against women, advocating for it to be reported and investigated and for a social shift which recognises male violence against women as abuse rather than normalising it and blaming victims rather than perpetrators.

The Circle has been working on improving maternal healthcare in Ghana, where 75 women a week die due to complications in pregnancy and childbirth. The focus here is on the provision of free healthcare to reduce maternal mortality. This is an achievable goal: other, non-Oxfam projects worldwide have shown the marked success of dedicated maternal mortality, pre- and ante-natal and newborn health projects. Please see my reports on Sierra Leone and Burundi and India for more details.

Two women's co-ops in Liberia have been helped to provide women with tools and training and empower them to bargain for better terms in a country in which, says Oxfam, "80% of ...women are unemployed." One little note to make here to correct that subtle patriarchal diss: these women, I can bet you, are employed. They are totally employed, to the point of exhaustion. They are employed in the never-ending, repetitive, back-breaking, all-consuming drudge labour of looking after the children, serving the men, running a household, cooking, cleaning and everything else - and these are all separate jobs - and their work is used and taken and exploited for free. They are paid nothing for their 24-hours, 7-day-a-week employment and it is callous and disrespectful to say that these same women are "unemployed." It is more accurate to say that they are exploited in an unjust situation. Despite the work they do, they are economically dependent on men and marginalised by them from economic power, political status, public influence and social clout. This exploitation and depletion of energy, financial and legal marginalisation and political discrimination mean that it is difficult for women to fight together for equality, rights and freedom from violence.

The latest addition to the Circle network is The Asian Circle, which works alongside Oxfam in helping South Asian women. It was founded and is chaired by Santosh Bhanot, the woman I met at the Kishwar Desai event. The focus is wide: The Asian Circle will be pulling together high profile women to support projects in agriculture, education, disaster relief and management, poverty reduction and sustainable development.

The Asian Circle was launched at the Houses of Parliament on 7th November 2013 in an event chaired by BBC reporter Ayshea Buksh and featuring speeches by Southall Black Sisters activist and journalist Rahila Gupta (read some of her human rights focused pieces here) and Kishwar Desai.

Santosh Bhanot spoke at the launch of The Asian Circle:




This week she told me,

Our focus is to work towards change with the skills and talents of ...[the] women who are part of the Asian Circle, a group of passionate and highly influential women from all walks of life. I wanted to help women who have an unfair chance in life and I particularly have passion and energy to work with women in South Asia because of my roots [as a South Asian woman]. Every woman has basic human rights.

On my recent visit to India I saw the positive impact of programs by Oxfam working with vulnerable women. For instance, building support centres for women subject to domestic violence and providing mediation and legal support. More programs are needed, especially in the poorer states.

The first programme The Asian Circle is supporting is called "Promoting Violence Free Lives." According to the Indian National Family Health Survey Round III report of 2005-2006 and the Oxfam India 2010 Baseline Survey, the statistics are damning, as are the social values which have been revealed:

• 35% of women suffer sexual or non-sexual violence in India
• 72% of men believe male violence against women is justified
• 68% of women believe that husbands are justified in beating wives

Rahila Gupta welcomes the connection between the feminism, profile and zeal of The Asian Circle and the structural support Oxfam can provide:

This is the launch of a very important initiative. If my last 24 years with Southall Black Sisters has taught me anything, it is this: funding, funding, funding. The time that we would like to spend delivering frontline services is spent instead on raising funds without which we'd have no money to deliver anything. So it's great that the Asian Circle aims to help Violence Against Women projects in India escape that vicious cycle.

The Asian Circle is focusing on the poorest states with a multi-tiered, thorough strategy: to build support centres in police stations for women who have suffered gendered violence; to engage community elders, young men and boys through educational initiatives to change their attitudes and their behaviour; and to develop networks of women working at a state level to make sure that domestic violence laws are implemented rather than ignored.

Kishwar Desai told me,

As someone who has been trying to raise awareness about some very disturbing gender issues in India for a while now, I am sincerely grateful to see the formation of The Asian Circle. My personal hope? That they will be the catalyst, eventually, for providing an international platform for Asian women, perhaps leading to a women's liberation movement in Asia.

Bidisha is a 2013 International Reporting Project fellow, covering 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.