Changing Priorities

Today, numerous Bangladeshi women are taking charge of their personal and professional lives. However, widespread gender bias and violence continue to challenge their dreams of emancipation and empowerment. Have the two women Prime Ministers of Bangladesh made a difference in the life of an average woman?

South Asian politics is dominated by dynastic trends and the presence of women leaders at the helm of affairs. The former is an unfortunate reality but the latter should be a source of pride for developing nations that have traditionally struggled with gender issues to provide their women with some very basic human rights. Whether it is the assassinated former Prime Ministers Benazir Bhutto of Pakistan and Indira Gandhi of India, or the still vibrant Khaleda Zia and Sheikh Hasina of Bangladesh, we must credit these women for their determination and persistence against the norms of their male-dominated cultures. Unfortunately, however, that is not a testament to women’s empowerment because not only do most of these women leaders have a strong male connection as primary reason for their rise to power, but also the life of an average woman has remained largely unchanged under their rule.

Bangladesh is a developing nation of 165 million with an adult literacy rate of about 55%. It has been run almost exclusively for the past two decades by Bangladesh’s two Begums – current Prime Minister Sheikh Hasina of Awami League (AL), and opposition leader and former Prime Minister Khaleda Zia of Bangladesh Nationalist Party (BNP). Sheikh Hasina is the daughter of Sheikh Mujibur Rahman, Bangladesh’s independence hero and first prime minister murdered in 1975. Khaleda Zia is the widow of former president, Maj. Gen. Ziaur Rahman assassinated in a failed coup attempt in 1981.

As Prime Ministers, the Begums have been known to run corrupt regimes, and faced criminal charges. In 2007, the army tried to end their monopoly on power when it seized power by splitting their vote banks and trying to create alternate forces. However, the Begums’ parties proved resilient and Sheikh Hasina came back to power in Dec 2008 and promptly resumed business as usual by filing more corruption charges against her opponent.

It is safe to say the last two decades have seen Bangladeshi women become more visible on the social and professional scene, but the gains have fallen short of expectation, especially under successive women Prime Minsters. So while the Begums focus on each other, the majority of women fight their own battles at home and in the social sphere against harassment, assault, kidnapping, acid throwing, and murder over dowry disputes.

Amnesty International reported that in 2010 police had received more than 3,500 complaints of physical abuse of women over dowry disputes, and in 2011, violence against women topped all crimes reported to the police between January and June, and 1586 out of 7,285 complaints were of rape cases. Due to prevalent patriarchal social attitudes, women in general, but especially from low socioeconomic backgrounds, lack access to resources for protection or legal redress. Domestic violence, however, transcends class barriers and acid-throwing is a brutal favoured punishment of spurned suitors or disgruntled husbands. There is also extensive trafficking of women to other countries in Asia and Middle East, lured by job prospects but forced into prostitution.

Moreover, The Daily Star quoted United Nations World Food Program (UNWFP) on International Women’s Day 2012 asserting that much effort was still needed to improve the lives of women in Bangladesh. The report said that almost half of the female population in Bangladesh is married before reaching 16, which results in higher pregnancy rate in adolescence, and undernourished mothers then give birth to underweight babies. Many young girls are still denied schooling and face bleak futures. UN Secretary General Mr. Ban Ki-moon urged the government, civil society and the private sector to work for gender equality in Bangladesh, which had not kept pace with strides in economic development.

Clearly, Bangladesh’s economic gains are not fully transferred to its women though their contribution to the economy is substantial, especially to the garment industry which is the source of 90% of Bangladesh’s foreign exchange. Institutions like Grameen Bank and BRAC have revolutionized the lives of many rural women by extending micro-credit to them, and have contributed to their economic empowerment, but unfortunately, Grameen Bank founder, the Nobel Laureate Muhammad Yunus, has been attacked by Sheikh Hasina, ironically again, in what is seen as a political move.

Gender bias has also often surfaced through religious expression. In April 2011, CNN reported   that when the government announced its Women Development Policy 2011 about inheritance of property, protests broke out from the radical Islamic parties that considered it a violation of the Quran’s injunctions about inheritance. Ironically, the opposition party BNP of Kahleda Zia was reported to be supporting the protest, undermining the cause of women’s empowerment just to gain some political mileage.

In July 2011, Human Rights Watch reiterated its concern for Bangladeshi women who are increasingly on the receiving end of religious fatwas issued by so-called scholars, even against the rulings of civil courts, in shalishes, the traditional dispute resolution methods. These decrees have resulted in humiliating punishments resulting in death for young girls wrongly accused. The punishments include imposing fines, lashing, cutting hair or blackening faces, and ostracizing families, carried out by vigilantes. While many of these incidents go unreported, human rights groups claim at least 300 such incidents have occurred in the last decade. In 2011, one particular case in Shariatpur district highlighted the seriousness of the issue when the shalish ordered 100 lashes to Hena Akhter for an alleged affair, when she had reportedly been sexually abused. She collapsed while the punishment was being carried out, and later died. Thus, the government’s failure to effectively address such incidences and implement legislation continues to result in grievous harm to women under the watch of their woman Prime Minister.

 It should be a matter of pride for Bangladesh that in November 2010 it was elected to the board of UN Women, but to do justice to this role Bangladesh’s Begums need to shift focus from personal and political gains and use their position to aggressively to work towards emancipation and empowerment of the average woman. Only then can the Bangladeshi women be truly proud of their Begums. 

A version of this article was published in SouthAsia, April 2012, as Changing Priorities

The AIDS Challenge

Feature

Each year December 01 is celebrated around the world as International AIDS Day to renew the commitment of the world community to spread awareness and find ways to combat this disease. There are an estimated 36 million people currently living with HIV and AIDS worldwide, of which at least half are women and 98% of these women live in developing countries.

AIDS (Acquired immunodeficiency Syndrome) is a disease that weakens the immune system and  makes the victim vulnerable to infections and cancers that may result in death if left untreated. AIDS is caused by the HIV (human immunodeficiency virus), and is spread through contact with infected blood or secretions. Since the HIV epidemic is largely connected to behaviours that expose individuals to the virus, studies have focused strongly on awareness and promotion of safe sex as being at the center of HIV prevention strategies. Risk factors that encourage the spread of disease in developing countries, especially in Asia which houses 60% of the world’s population, include low literacy rates, crippling poverty, high fertility combined with low contraception usage and topped by poor access to health and education facilities.

Pakistan is the second largest country in South Asia, and WHO and UNAIDS estimate the number of HIV/AIDS cases in Pakistan to be around 90,000, while national statistics report them to be at a modest 5,000 – the discrepancy points to the fact that a vast majority of cases go unreported due to social taboos about sex and victims’ fears of discrimination. Pakistan has been a low HIV prevalence country with only 0.1% afflicted among its general adult population, but is increasingly faced with a threat from a high number of injecting drug users (IUDs) and has now moved into what is known as the transition phase.

To respond effectively to this threat, Pakistan started its National AIDS Control Programme (NACP) in 1986, which has shown productive outcome in line with its objectives of “prevention of HIV transmission, safe blood transfusions, reduction of STD transmission, establishment of surveillance, training of health staff, research and behavioral studies, and development of programme management.” NACP program partners include World Bank, WHO, DFID, CIDA, GFATM, GTZ, UNAIDS, UNODC, UNFPA, UNICEF, UNIFEM, CDC Atlanta, Clinton Foundation and the GFA Consulting Group. The NACP through its centers across the country has made possible access to treatment and information to many victims, while maintaining data and providing research opportunities towards the larger goal of prevention and eradication despite facing challenges. The NACP is also providing free treatment to patients in its 20 centers across the country.

The modes of HIV/AIDS transmission in Pakistan relies largely on heterosexual transmission and contaminated blood or blood products as the most commonly reported vehicles. Other transmission methods include injecting drug use, male-to-male or bisexual relations and mother-to-child transmission, while HIV prevalence is 1% to 2% in high-risk populations such as female sex workers and long-route truck drivers.

Pakistan’s general population finds itself at potential risk through an general attitude of low compliance with infection control procedures including handling of blood transfusion and use of unsterilized medical instruments. Studies indicate that a high percentage of injections are administered with used injection equipment due to shortage of funds. According to WHO estimates, unsafe injections account for three percent of new HIV cases in Pakistan. It is also estimated that 40 percent of the 1.5 million annual blood transfusions in Pakistan are not screened for HIV. Moreover, in 1998, the AIDS Surveillance Centre in Karachi conducted a study of professional blood donors and found that 1% of them were infected with HIV.

IDUs remain at a considerably higher risk of contracting HIV infection in Pakistan because they often indulge in high risk practices of sharing syringes. Since Pakistan neighbours a major opium producing country, Afghanistan, a percentage of its vulnerable young-adult population has been addicted over the years. With a growing number of drug abusers, in 1999 the United Nations Office of Drugs and Crime (UNODC) had conducted studies in Lahore on changing methods of drug ingestion from inhaling to injecting, and warned of a rise in HIV cases. As predicted, the country saw an increase from 9% in 2005 to 21% HIV prevalence among injecting drug-users by 2009.

While there is little documentation about homosexual relations in men in Pakistan due to religious and cultural taboos, evidence from various studies suggests it is prevalent throughout the country. According to WHO, "Asia is believed to have the world's largest number of [MSM], estimated at 10 million.” Sexual activity between men is likely present in boys’ hostels and jails, and in the groups of transvestites, transsexuals and eunuchs who are known to engage in unsafe sexual practices due to their disadvantaged socioeconomic and educational status.

Gender inequalities are also known to facilitate the further spread of HIV/AIDS among women in male dominated cultures in Asia in general. The status of women in Asia makes them especially vulnerable to HIV, and they suffer from a lack of access to support systems for HIV too. The number of women infected with HIV in Asia rose to 20 percent between 2003 and 2005, compared with a 17 percent increase for the region's total population, (UNAIDS 2005).

Pakistani women in general have less socio-economic independence and have less decision-making power than men. Gender disparities are rampant in many fields, e.g. female literacy rate in Pakistan is at 35% for women and 59% for men. Despite social stigma, commercial sex is also prevalent in all major cities of Pakistan. Owing to their low social status, female sex workers (FSWs) are often exploited and abused, and have little legal recourse or protection. Many behavioral studies indicate that female sex workers have little or no understanding of safe practices which makes them more vulnerable to STIs and HIV/AIDS. Furthermore, these sex workers often lack the power to negotiate safe sex or seek treatment for STIs and one study indicated that only 2% of female sex workers said they used any form of contraception with clients.

A big hurdle in treatment options for women is, however, the stigma attached to being related to an AIDS patient. Many women are shunned by not only their neighbours, but also close family members for the crime of association. Sometimes, after losing the husband to AIDS, women become more vulnerable to abuse. They face open hostility, and their children also suffer social isolation. Many women are excluded from inheriting property, cast out of their homes by in-laws and end up with severe food insecurity and lack of long-term sustainable livelihood as well as lack of support and care systems for treatment and life-saving drugs. Children of these women, or those born to HIV positive mothers, suffer widespread discrimination too. UNICEF sources claim only 38% of children under 15 living with HIV in the developing world received antiretroviral treatment which is considered extremely important for sustainability of victims.

The epidemic of HIV/AIDS in the developing world requires a consistent focus of respective governments and constant support of the world community in employing effective strategies based on timely prevention of HIV transmission, safe blood transfusions, training of health staff, continuing research and development of program management on a large scale, supported by an enabling environment. Hopefully, the World AIDS Day will serve to keep the focus on this important issue alive.

SOUTHASIA, 'The AIDS Challenge, Dec 2010.

Investing in Healthcare

Feature

Access to healthcare is a basic human right. The World Bank is playing an important role in helping South Asian countries to provide this right to their citizens.

Developed countries of the world have in place a robust infrastructure and institutions that see to the provision of these rights, while developing countries struggle with funds and weak healthcare systems. When resources fail to meet demand, various world aid agencies help bridge the gap with financial and technical assistance. The World Bank has been a consistent supporter of South Asian governments in tackling serious health issues like HIV/AIDS and Polio mellitus.

HIV/AIDS

Acquired Immune Deficiency Syndrome (AIDS) weakens the immune system and exposes the body to infections. Although AIDS was first recognized by the US Center for Disease Control (CDC) in 1981, in its third decade it still eludes a cure, there is no vaccine and preventive measures involving practices of safe sex and Syringe Exchange Programs (SEPs) have been advocated as the best approach. In 2007, roughly 33.2 million people lived with AIDS worldwide. An estimated 2.1 million people have also died of it.

Epidemiologists have conducted extensive studies to understand and identify high risk groups and formulate effective management strategies. However, South Asian countries present a unique challenge because of their population diversity which hampers effective management. The World Bank’s report, AIDS in SA: Understanding and responding shares the scope and dynamic of this infection in South Asia. It points out the most vulnerable groups as being Sex Workers (SWs), their clients, homosexual men (MSM), and Injecting Drug Users (IDUs). Once infected, these groups are more likely to transmit infection to large numbers of contacts.

These high-risk groups are present in significant numbers in some South Asian countries. In 2004, India harbored more than 60 percent of the HIV infections in Asia (UNAIDS). In 1998, Prime Minister Vajpayee declared HIV/AIDS as “India’s most important public health problem.” India has a legalized sex industry and at least 500,000 female sex workers (SWs). These SWs are receiving help and information regarding safe sex practices to control the pace and spread of infection. In countries where sex is not a legalized industry, most SWs operate from homes dissemination of information becomes a challenge. Sri Lanka, which has an estimated 30,000 female SWs, is also estimated to have 40,000 to 50,000 drug users. Pakistan has about 500,000 chronic heroin users (UNODC 2002). Figures from neighboring Afghanistan show that, of an estimated 920,000 illicit drug users, 120,000 are women and 60,000 are children (UNODC 2005).

The Detailed Implementation Review (DIR), a World Bank, document gives information on WB contribution in this regard: The World Bank had been a consistent supporter of initiatives in South Asia and has financed HIV/AIDS prevention and treatment programs extensively. In 1992, a World Bank (Bank) assessment revealed that India could “follow in the footsteps of some of the worst affected countries in Africa, resulting in the erosion of many of the past gains in human development.” WB sponsored the Indian government’s National AIDS Control Projects (NACPI, NACPII) and in 1998 the Bank was acknowledged to be its single largest donor. The positive results of the project have now been acknowledged widely.

The World Bank has also conducted studies to help governments understand the best approaches. For South Asia, the costs of treatment to the disease-afflicted populations and consequently, the economy of the country is a serious concern. Mariam Claeson, WB's HIV/AIDS Coordinator for South Asia explored the impact on economic growth in South Asia in the report,’ HIV and AIDS in South Asia’ as a regional development issues: “Although HIV prevalence in South Asia is comparatively low, the region faces a number of challenges including the risk of escalation of concentrated epidemics, the economic welfare costs, and the fiscal costs of scaling up treatment for AIDS. If HIV infections are distributed across the range of South Asian living standards, then only 30 percent of the cases would be above the more generous poverty line of US$2.15. And the poorest 10 percent of these would be pushed down into poverty by AIDS treatment expenditures.” Preventive strategies have thus been propagated as the best approach.

POLIO MELLITIS

The Global Polio Eradication Initiative was launched in1988; polio was endemic in 125 countries around the world at the time, and 350,000 children a year became paralyzed because of it (WHO). Thanks to the successful global polio vaccine campaign over the past 20 years, it exists only in four countries including three Asian nations (India, Pakistan and Afghanistan) and one in Africa (Nigeria). These countries remain a cause of grave concern as travel to and from these countries challenges containment, and eradication continues to be an elusive goal despite an expenditure of more than $6billion so far.

For Pakistan and Afghanistan, war and instability seems to be a contributor in the spread of polio. In the latter half of 2008, large scale movement of populations from the Northern areas of Pakistan took place due to militant violence and resulting military action. The Internally Displaced Persons (IDPs) from war-affected areas took up residence in camps or with relatives in other parts of the country and the virus moved into areas previously considered free of it. The recent floods have again rendered almost 20 million homeless and forced them into camps. Although updated assessment of spread of disease among them is not currently avialable but it is predicted to be a helathcare nightmare unfolding slowly but surely. In Afghanistan, ongoing decades old war continues to hamper administration of OPVs to affected areas.

The Director of Polio Eradication Initiative at WHO, Dr. Bruce Aylward, in his report to the World Health Assembly said that 2008 was “a very difficult year for the eradication programme." in Nigeria because there was” "a simple failure to reach and vaccinate children,” According to the disease surveillance unit of the WHO, Nigeria accounts for 61 per cent of global polio cases and 95 per cent of cases in Africa. Although southern Nigeria has been polio-free for a couple of years, northern Nigeria, in 2003, stopped immunizing its children against polio when hard-line Nigerian clerics called for the boycott. The result was the spread of polio virus from Nigeria to 23 polio-free countries around the world, including nations as far away as Indonesia and Yemen, effecting nearly 1500 children. The reason for persistence of disease in the Pakistan and Afghanistan rests on similar misconceptions regarding the contamination of polio vaccine with infertility drugs and AIDS virus. This has resulted in stiff resistance against polio eradication campaigns and threats to government and aid officials, challenging containment efforts in these countries

The governments of Pakistan, Afghanistan and Nigeria are trying to reach people through media and religious leaders to remove misconceptions. The campaigns are not likely to meet with success despite support form World community unless religious and cultural concerns are addressed. The number of reported cases in 2009 clearly show more needs to be done – 57 in Pakistan, 22 in Afghanistan, 327 in India and 379 in Nigeria (Global Polio Eradication Initiative) The World Bank is part of the ‘Partnerships for Polio Eradication Project’, and its IDA is providing additional financing of $50million would finance the increased resources required for the procurement of Oral Polio Vaccine (OPV) in support of Nigerian government’s efforts. In Pakistan, the World Bank has supported all initiatives for Polio Eradication. The combined World Bank financing for Polio eradication in Pakistan during 2003-2007 amounts to US $110.78 million. The Bank also approved the credit of US$74.68 million to Pakistan for a Third Partnership for Polio Eradication Project.

While the work done in the health sector of the South Asian countries has been universally recognized and appreciated, some strong criticism has also been noted of the WB policies setting strict financial pre-requisites and asking countries to raise interest loans and reduce government spending in order to get bailout loans during periods of economic decline. Mark Levinson wrote in The Cracking Washington Consensus, how “International financial institutions, the World Bank and the International Monetary Fund (IMF), pressed developing countries to conform to the formula as a condition of their loans.” He also quoted a study from the Center for Economic Policy research which states that , “there is no region of the world that the Bank or Fund can point to as having succeeded through adopting the policies that they promote—or in many cases—impose on borrowing countries.”

There may be truth in that criticism, but it is also a fact that many critical healthcare initiatives in South Asian countries may not have come about without the active support and engagement of World Bank. For this reason, South Asia continues to partner closely with the World Bank to achieve its goals.

SouthAsia Magazine "A Healthy Future" October 2010

Motherhood Redefined?

Are all alternative arrangements to human limitation justified?

Traditionally, a mother may be defined as a female who is the biological parent, related through marriage to a biological father, or through a contract of adoption. However, procreative options have multiplied over the years to include a surrogate as a third party in the usual two-party parenthood equation.

A surrogate mother is defined in The Columbia Encyclopedia, Sixth Edition, as “a woman who agrees, usually by contract and for a fee, to bear a child for a couple who are childless because the wife is infertile or physically incapable of carrying a developing fetus.” The resulting offspring may be a biological offspring of one or both parents. The book, “Children of Choice: Freedom and the New Reproductive Technologies” authored by John A. Robertson, calls this arrangement, “Reproductive Collaboration”.

In recent years, India has placed itself on top of the reproductive outsourcing industry owing, mainly, to medical expertise, low costs and a relaxed legal atmosphere. The surrogacy industry in India is considered to be at a value of $445 million/year, by some estimates. Commercial surrogacy was legalized in India in 2002. In the absence of a proper legal framework, the surrogates sign a contract handing over all rights to prospective parents according to the guidelines issued by the Indian Council of Medical Research. Since the name on the birth certificate is that of the biological parents, the process of taking the baby out of the country is also carried out with relative ease. Contrarily, pre-signed contracts hold no legal standing in many US states wherein the surrogate is required to sign over her rights at the time of delivery. If she chooses to assert her claim, however, she has a window period after birth to file that in.

Multiple reasons push couples towards this option, like repeated miscarriages and IVF failures, a hysterectomy or a diseased/damaged uterus etc. However, Dr. Nayna Patel who runs the popular Anand Clinic in Gujrat, India, has admitted to having received requests by women who have none of the medical reasons to go for surrogacy, "I've had some women ask to do surrogacy because they don't want to give up work for a pregnancy, but I turned them down flat." To want to use poor women from developing countries as human incubators to produce their off springs, while not compromising their work, health and physical attractiveness raises some serious ethical questions that further complicate the issue.

When fertility clinics match prospective surrogates with infertile couples, elaborate screening and counseling is done to ensure a harmonious transaction. Indian women, belonging to a largely conservative society, are believed to maintain a generally healthy lifestyle devoid of alcohol and drug abuse, though various poverty-related environmental factors affect their health in other ways not always taken into consideration. The chosen surrogates are usually below the ages of 40 and are married women with at least one live birth to show for credible reproductive capacity.

In the absence of an effective social services network or support system, the surrogates are left to deal with the trauma of delivery and separation all by themselves. However, fertility experts like Dr. Patel insist that "Many surrogate mothers see this not as 'handing over' the baby, but as 'handing back' the baby, as the baby was never theirs to keep." To avoid stigma and condemnation from their conservative society, often these women keep their services secret from their relatives.

The cost factor remains one important reason for these couples to look to the Indian industry. Anuj Chopra wrote in April, 2003 in the Christian Science Monitor about a couple from London who found a surrogate mother in India, paying her $9,720 for a service which would have cost them three times more in UK. The cost for surrogacy in the US comes to around $75,000 as compared to an average of $25,000 in India, including the complete costs of travel and treatment. The surrogate receives approximately $6,000 to $7,000, which is a small fortune by local standards. Many surrogates have disclosed using the money for buying property or paying for their children’s education. Some have even used it to get expensive medical treatment for family members otherwise beyond their grasp.

Opinion on the moral, ethical and legal issues surrounding surrogacy vary considerably worldwide. Surrogacy was outlawed in 1991 in France by the highest court and it was declared that, "The human body is not lent out, is not rented out, and is not sold." In Australia it is illegal to pay a surrogate mother apart from her medical expenses. In Germany, sperm and egg donation are not allowed, based on the idea that every child has a right to know and be raised by their own parents. In some other countries like Sweden and Spain efforts to legalize surrogacy have received wide condemnation, while some other western countries evaluate surrogacy requests on a case-to-case basis through independently formed Ethics Committees.

The Oprah Winfrey Show aired an episode titled, ‘Wombs for Hire’ on October 09, 2007 anchored by Lisa Ling of ABC and The National Geographic. It received some strong criticism for calling the desire of commissioning couples from richer nations to find surrogates from poor countries as a case of “women helping women”, rather than exploitation of the surrogates’ economic desperation. When Lisa asked the commissioning mother in question about her views on this, she tearfully responded with, “Sangita and I give each other a life that neither of us could achieve on our own.” Literally speaking, that might be true but the program has been criticized by viewers for not addressing more critical moral and legal questions regarding the rights of the surrogate in case of complications, rights of a baby born with genetic abnormalities, DNA testing to ensure paternity, or issue of the donor’s unused egg disposal and the like.

Another moral dilemma rises when surrogacy is likened with prostitution as it involves the appropriation of women’s bodies for money. While some call it empowerment of poor women, others insist it is nothing but degradation and exploitation. Merits of adoption have long been propagated as the real solution to the problem of childless couples, yet the desire for becoming a biological parent remains.

Commercial surrogacy is a complicated issue and opinion is deeply divided on its various implications for individual and society at large. It will take a long time yet before we can make the choices of individuals consistent with values of their societies in a rapidly evolving world. The use of services such as commercial surrogacy requires regulation and clearly defined framework to prevent misuse and injustice to all concerned.

SouthAsia July, 09

Investment into the Future

South Asia is considered to be a region that promises dynamic growth and potential. However, it lacks in some crucial elements of social development that risks its progress; and education and health are two factions high on the list. The World Bank is aware of the significance of this part of the world and true to its mission to “help people help themselves and their environment by providing resources, sharing knowledge, building capacity and forging partnerships in the public and private sectors.”

The World Bank is a vital source of technical and financial assistance for many developing countries as it supports initiatives essential for the countries’ progress and stability. It was founded in 1944 and consists of two institutions; the International Bank for Reconstruction and Development (IBRD) and the International Development Association (IDA) that provide low interest loans, interest free credits, and grants for investment in development initiatives in the field of education, health, public administration, infrastructure, financial and private sector development, agriculture, and environmental and natural resource management.

In South Asia, the World Bank has supported several programmes over the years to increase literacy rates and support development of a healthy, skilled workforce as an investment into the future. However, many social challenges faced by the developing countries of South Asia affect their progress including extreme poverty, low status of women, orphaned children, unemployed youth and war ravaged widows, shortage of well-trained professionals and sometimes a lack of commitment by governments towards effective management. These developmental issues pose challenges for policy planners and practitioners and require constant evaluation and adaptation of strategies in order to meet the goals.

Since South Asia is home to some of the world’s poorest countries, literacy does not always fare well on the priority list. The estimated percentage of people living below the UN defined poverty line of less than $2 a day is 40% in Pakistan and 84% in Bangladesh. In India, 75% of the population lives on less than $1/day, according to a World Bank study. In these societies, keeping children out of school is not seen as a violation of their rights, but simply a means of survival. India also has 18 million street children, the world’s largest concentration (HRWA 2000), while Nepal is home to about 30,000 street children according to a 1996 estimate. These school-age children constitute the marginalized group often neglected by governments when implementing welfare schemes.

Moreover, widespread gender bias and discrimination exists in societies across the globe and an estimated 2/3rd adults without access to literacy worldwide are women. In most of the patriarchal societies of South Asia, it is even more rampant. However, there is a source of relief for development experts in the tiny Buddhist state, the Royal Republic of Bhutan with a population of 700,000. A 2007 Country Report on Human Rights Practices about Bhutan issued by the US State Department revealed that about 30% of Bhutanese women constituted the formal workforce in 2004 and 60% of women held land registration titles. A recent WB study has also shown near gender parity at 93% at primary level. The World Bank programmes in Bhutan focus on improving quality of education, strengthening institutional capacity, teacher training management and monitoring.

Similarly, Bangladesh takes pride in achieving gender parity at the primary and secondary school level, and primary school enrollment shows a steady upward trend with 91% girls and 87% boys enrolled in 2007 (UNICEF). The World Bank provides assistance to Bangladeshi government at the primary and secondary level, reaching out-of-school children and continuing-education projects. Another success story is Sri Lanka which has one of the best performing education sectors in South Asia. With primary enrollment of boys and girls well above 90 % for two decades, and a secondary enrollment rate of above 80 %, through a network of state-supported schools, the commitment of the Sri Lankan government and society can certainly serve as a source of inspiration for others to follow.

Pakistan’s participation in the education sector remains among the lowest in South Asia, with just 2.3% of the GDP allocated to this sector, and widespread gender bias. In the more conservative Northwest of Pakistan, cultural customs clash with religious sentiment and access to schools for girls has been a grave issue in the past years with extremist clerics declaring modern education as un-Islamic and misleading. Small wonder then, that only 14% of the formal workforce in Pakistan comprises of women. The World Bank is making a significant contribution towards quality education and policy reforms in educational institutions in Pakistan. A series of four one-year education development policy credits in the Punjab province has resulted in an increase in enrollments in 15 districts which had been identified as having the lowest literacy rates. The reforms in NWFP and Sindh showed similar benefits, as gross primary enrollment among girls increased between 2001- 2002 by 11%. Another important programme of the World Bank in improving the quality of learning in Pakistan is monitoring of student learning through regular assessments with a National Education Assessment System. A Higher Education Support Programme is in the starting phase, and the private sector is being supported through education foundations. In June 2009, World Bank also approved $900 million in loans, most of which would serve to improve education in Pakistan’s Punjab and Sindh provinces as the country has also had to battle with a balance of payments crisis in the last one year due to fighting in the northwest of the country which has left 2.5 million Internally Displaced Persons (IDPs) struggling to survive.

The issue of children belonging to conflict zones has also drawn attention from the humanitarian agencies. In Sri Lanka, in the North-Eastern Province alone, it is estimated that 2,000 children have been involved in guerilla warfare as child soldiers, and face difficulties readapting to age-appropriate, stable lifestyles. Education in crisis situations can actually provide children with a sense of normalcy, but unfortunately, the first Global Survey on Education in Emergencies shows that “over 27 million children and youth do not have access to education in 10 countries affected by conflict.” Other disabled children and young adults of war-torn countries like Afghanistan are left with very few options in societies already stretched thin in terms of resources.

In Afghanistan, there are serious developmental concerns regarding status of women and absence of a well-educated and skilled workforce to build institutions, as the country struggles with almost three decades of war and instability that have resulted in huge numbers of widows and orphaned children. Hence education, skill development and vocational training programmes are taking priority. It is hoped that WB’s Afghan Skill Development Project which is estimated to cost US $35million (WB is providing US $20 through the IDA), will bring in some respite for these vulnerable sections of the population.

Moreover, the World Bank’s reform programmes are working with governments in recruitment and monitoring of teacher presence. South Asia’s schools lack sufficient number of qualified teachers and present a huge challenge to the goal of universal education. In Pakistan, the student/teacher ratio is 1:35 in primary schools and 1:48 at secondary level while in 75% of Indian schools there is only one teacher for several classes. Bangladeshi pupils are found to be in the most crowded classes, with a ratio of 1:57. More serious, however, is the presence of ‘Ghost’ schools in remote areas where teachers simply don’t turn up. A 2004 World Bank study in India showed that 25% of teachers are absent from class at any time.

The World Bank is also providing technical support and conducting joint research and analysis exercises on improving access for girls and other marginalized groups in different countries of the region. Since 2000, the World Bank has committed over US $1 billion to education in India. However, extensive inter-regional, rural-urban and male-female disparities exist despite the government’s commitment to the cause of ushering in ‘a new era’ of literacy. As reported in an article in Asia Sentinel, August 2009, “a third of India’s billion-strong population is illiterate and 70 million children are denied schooling of any kind.” A US $250 million World Bank operation is also helping improve India’s technical and engineering education.

Educational challenges in South Asia continue to be daunting, but it would serve South Asian governments and citizens well to realize that in order to build any kind of potential for economic prosperity, they must show an unwavering commitment to initiatives that can help build a future for themselves and their coming generations.


Published Oct 2009 Investment Into the Future, SouthAsia Magazine

Escapism from Life - suicides in Southasia

Suicide is a major cause of death around the world. Are developing countries of South Asia equipped to handle this challenge?

The World Suicide Prevention Day is held on September 10th every year since its creation in 2003. The event, organised by the International Association for Suicide Prevention (IASP) revolves around issues such as improving education about suicide, disseminating information, decreasing stigmatisation and, most importantly, raising awareness that suicide is preventable. The event is being co-sponsored by the World Health Organisation (WHO). To highlight the importance of keeping cultural context in view when devising strategies for suicide prevention, the chosen theme for 2009 is "Suicide Prevention in Different Cultures.”

The magnitude of this problem is highlighted by the statistics provided by the WHO. Suicide has been noted as the leading cause of death in individuals under 35 - an estimated 10 million people attempt suicide while one million actually succeed in ending their lives every year - that's one death every two minutes. By 2010, the WHO estimates the number will climb to 1.5 million.

South Asia is home to a major part of the world's population and is estimated to account for up to 60% of all suicides. Though the WHO warns of rising suicide trends worldwide, the Dutch suicidologist, Diekstra fears that the most dramatic increase in suicide mortality in the next decades will be observed not in the developed world but rather in the developing countries. Statistics from the WHO on suicide in some South Asian countries seem to support Deikstra's trend predictions:

• In Bangladesh, the number of suicides between 1972 and 1988 averaged at 600 suicides per month, while 1992-1993 saw an increase of 984 suicides per month. The total number of suicides reported to the Forensic Medicine Department of Dhaka Medical College indicates that suicides have increased from 12 per month in 1989 to 18 per month in 1998.

• Suicide rates in India average at 11 suicides per 100,000 persons per year, an increase from 6 per 100,000 persons during the 1980s. While 89,000 persons committed suicide in 1995; the number increased to 96,000 in 1997 and to 104,000 in 1998, an increase of 25%. During 1988-1998, suicides increased by 33.7%.

• In Sri Lanka, it is estimated that nearly 50,000 persons have been killed in the last 15 years due to war. Deaths due to suicide, in the same period, are estimated to be 106,000 twice the number due to war. One study estimated the real extent of the problem was estimated to be at 44-50 suicides per 100,000 people. Significantly, the proportion of youth committing suicide increased from 33% in 1960 to 44% in 1980.

The trend of increased suicides in developing countries is further highlighted by other sources:

• The HRCP (Human Rights Commission of Pakistan) report for 2005-6 declares that total suicide and attempted suicide cases increased from 2,712 in 2005 to 3,919 in 2006. There were around 200 women suicide cases reported within the first six months of 2006 along with 181 cases of attempted suicide, most of the victims being under 30 years of age.

• While quoting The Khatmandu Post in the November 2008 issue, The Gulf Times reported that in Nepal, “the number of suicides reported by police rose by 40% in the past four years. Official statistics showed 2,789 suicides in 2007, up from 1,992 in 2004. The newspaper said 659 cases were reported during the first three months of 2008, keeping pace with the record 2007 total.”

• The BBC in July 2009 reported that according to official figures, Bhutan experienced its highest number of suicides in 2001 when 58 people killed themselves.With a population of just 682,000, the issue is of high concern in the country.

Suicide has become a grave concern for many South Asian countries, many of which are struggling with problems of massive corruption and mismanagement at every level. These alongside issues of poverty, unemployment, illiteracy, lack of civic facilities, poor access to health facilities, and disproportionate population growth are preventing the governments to adequately focus to solving the suicide crises. Governments spend only a small fraction of their national budget on social and health sectors which in turn enhances the frustration experienced by citizens on social and cultural pressures and thus drives many individuals towards self-destructive behaviour by inducing in them feelings of guilt, desperation, anxiety, and even serious mental health problems. Stigma and discrimination by society allows many of these health problems to go unchecked, with devastating results for the whole community.

Women in the South Asian countries remain particularly vulnerable to suicide because of numerous factors including social and cultural pressures, domestic and sexual violence, and undiagnosed or untreated mental illnesses. A World Bank study that focused on disability from neuropsychiatry disorders among women found that up to 30% women were affected in the developing countries as compared to 12.6% men. In Pakistan, a 2007 trend analysis report by the HRCP found young married women to be at highest risk. In Bangladesh, a 1996-97 survey on injury-related deaths among women found that suicides have a major effect on mortality among young married women and almost 50% women reported having suffered verbal, physical and sexual abuse at the hands of their husbands. Many women in patriarchal societies blame the effects of gender inequality to be a major cause of their low status and consequent distress.

According to WHO, preferred methods of suicide vary from culture to culture as do motivations: Of the suicide related attempts, suicide by hanging is chosen by 26% in India and 45% in Bangladesh while self-burning (immolation) is commonly adopted in India by 11% individuals indulging in Deliberate Self Harm (DSH). Ingesting household products is the commonest method adopted by 70% of suicide seekers in Sri Lanka and 37% in India. Reports suggest that this problem is particularly significant in rural areas. The rising costs of seeds, pesticides and fertilizers have resulted in heavy debts for farmers and have pushed them to commit suicide by ingesting the same pesticides because of their easy availability. Pesticide ingestion results in approx. 250,000 deaths each year globally.

There also exists a serious issue of underreporting in some South Asian countries that hinders effective management of the issue. Attempted and successful suicide is underreported because of social stigma and also because committing suicide is a criminal offence in some countries such as Pakistan. Hence, many suicides are reported as accidents and actual figures elude statistical collection, posing a constant challenge to prevention strategies. Effective data gathering is also important in order to identify high-risk groups and establish timely preventive measures.

For developing countries, suicide prevention is a challenge that has devastating consequences for the society as a whole. Fewer resources and inadequate social services offer a tough test that many of these nations are trying to overcome with help from local social activists and international humanitarian agencies like WHO and the IASP.

Initiatives are conducted to emphasise support for people under stress, addressing issues like domestic violence for women, restricting access to common methods of suicide etc. More focus on media education about responsible reporting, and public awareness campaigns for mental health de-stigmatisation is needed in order to change cultural attitudes. Healthcare professionals also need to be trained to identify risk groups and provide sustained help and support. In short, there has to be a committed, sustained effort by communities, world humanitarian agencies and governments if suicide prevention goals are to meet any success.


Published Sept, 09. Escapism from Life - Suicide in SouthAsia SouthAsia Magazine

Existing Without Hope

Mental illness affects people around the world, transforming their lives into a continuous struggle for preservation of their dignity and human rights in societies that do not always understand them.

"All human beings are born free and equal in dignity and rights" states the Universal Declaration of Human Rights.

Throughout history, mental illness has been associated with factors like weakness of character or possession by demons. As a result, the mentally ill have been isolated, neglected, tortured and even burnt alive; their lives destroyed by stigma and taboo.


The progress in medical knowledge encouraged a scientific approach to mental health problems and resulted in a slow and steady change in attitude. Many people began to view mental disorders as illnesses akin to other diseases that required treatment, not condemnation; though many societies still continue to show disdain for the mentally ill, and their mental health services remain insufficient and ineffective.

Understanding mental disorders is a difficult task in terms of the dynamics of the disease and the heavy emotional and psychological toll it takes on family life. Care for the mentally disabled is a serious human rights issue because of its effect on societal harmony and stability and potential for exploitation and abuse. In many mental health facilities, rehabilitation is not always seen as the chief aim of treatment. Human rights violations against people with mental disorders occur in communities throughout the world – in mental health institutions, in the wider community, and at individual level.

The World Health Organization (WHO) strongly urges communities to ensure respect for human rights and dignity in all mental health facilities, and outside. According to WHO reports based on testimonies of the patients and their relatives, it has been observed that many patients face severe discrimination and endure appalling living conditions in the mental health facilities. The following are excerpts from some of the letters addressed to WHO:

1. "Among the professionals who dealt with my son's psychological illness, I frequently encountered irritation and threats aimed at him ('if you don't shape up' or 'I'm really having a problem with you today'), as if his psychological problems were subject to his direct control. In the 15 months of cancer treatment that my son also received, I never heard a nurse or doctor express any anger or irritation with my son for the symptoms of his illness."(Source: Weissman MM. A piece of my mind: stigma. JAMA, 2001, 285(3): 261-2.)

2. "I experienced homelessness at one stage coming out of the hospital. I had nowhere to go. I had no choice. My family at that point was struggling with their own view of my condition and there was no place in the family for me. If my family had been educated, taught how to help me, supported and helped, then my story would be very different. (Source: Stop exclusion – Dare to care. World Health Day brochure. Geneva, World Health Organization, 2001.)

3. "The conditions there are miserable… dirty patients; dishevelled and very skinny [patients] surrounded me asking me for some bread. As for the building, it is pitiful to look at: many broken glasses, walls without painting for many years …The toilets, totally out of order, without running water. Most of the time cooking is done with water caught from the rain.…"

The report goes even as far as to quote a health worker as saying, "Why are you fighting that much? This place is but the waste of society."

(Source: Letter 78, original in French. Voices from the shadows: a selection of letters addressed to the World Health Organization 1994 – 2002. Geneva, World Health Organization, 2004.)

Investigators from Mental Disability Rights International have found that inmates of mental health facilities who tried to escape were given severe punishments such as confinement for hours in cold, bare rooms without clothes; while over-drugged, unkempt and neglected patients pleaded for provision of basic needs like a glass of water. (A report by Mental Disability Rights International, September 2004)

WHO sources give a depressing analysis of the situation of mental health management worldwide: almost 64% countries have been found to have no legislation regarding mental health, or at least one that is less than ten years old. About 30% of countries don’t have a separately allocated budget for mental health; 20% countries spend less than 1% of their health budget on mental health; 32% countries have no community care facilities and vast differences are observed in the number of psychiatrists available to the populations ranging between more than 10 per 100,000 to less than 1 per 300,000. In Pakistan, though the fiscal year 2006-7 has seen a significant increase in the health budget, only 1% is estimated to be spent on mental health.

Researchers have found that factors such as low income, low education and difficult marital and family relationships expose women to abuse and make them more vulnerable to mental disorders. Accor-ding to WHO sources, the probability of developing anxiety and depression are higher among women as compared to men, and these findings are constant across a series of studies conducted in different setups. A study by World Bank (1993) that focused on disability from neuropsychiatry disorders among women found that up to 30% women were affected in the developing countries as compared to 12.6 % men.

Pakistan Association of Mental Health (PAMH) declares that of the estimated 44% Pakistanis suffering from clinical depression, the majority are women. In Pakistan, many of the plans working towards social uplifting of women’s health focus on their reproductive health and their psychological and emotional needs are generally not given due importance, as is the norm in patriarchal societies. Women as care-givers have multiple roles to play at home. The burden of responsibility for the household including efficient running of home and fulfilling the needs of immediate as well as of extended family members requires a lot of energy. This burden is further multiplied for working women who have no one to share the burden of domestic duties along with the demands of their job. A culture of suppression prevents women from finding healthy outlets to their frustrations. It is not surprising then that they become over-stressed and succumb to nervous breakdowns.

A serious trend manifest in the behaviour of the mentally disturbed is a tendency for deliberate self-harm. According to WHO sources, mental disorders are associated with 90% of all suicide cases; the last 45 years have seen a global increase of suicide rates by 60% and about 1 million people died of suicide worldwide in 2000. It is also among the top three leading causes of death of individuals aged 15-44 years. WHO finds that though traditionally suicide rates were highest among the male elderly, now the younger age-group mentioned above are at higher risk of suicide in a third of developing as well as developed countries, though reasons and methods vary.

In Pakistan women remain particularly vulnerable to suicide because of numerous factors including social and cultural pressures, domestic and sexual violence, and undiagnosed or untreated mental illnesses. Stigma and discrimination by society allow these mental health problems to go unchecked. The HRCP (Human Rights Commission of Pakistan) report for 2005-6 declares that total suicide and attempted suicide cases increased from 2,712 in 2005 to 3,919 in 2006. There were around 200 women suicide cases reported within the first six months of 2006 along with 181 cases of attempted suicide, most of the victims being under 30 years of age. A 2007 trend analysis report by the HRCP also found young married women to be at highest risk.

Attempted suicide is underreported because it is a criminal offence in Pakistan punishable by up to one year imprisonment, and many successful suicides are also reported as accidents due to stigma. Hence, actual figures elude statistical collection, posing a challenge to effective data gathering.

Effective treatment of mental disorders requires a multi-pronged and multi-tiered approach involving government and private sector, community health services, family support groups and access to individual counselling facilities. Increasing awareness about the rights of the mentally ill, countering stigma and discrimination, training of primary health professionals, improving standards in psychiatric institutions, restriction of access to common methods of personal harm, etc. may be some of the strategies applied in this regard.

People suffering from mental disorders are either not aware of their rights or are not in a position to claim them. It is thus the collective responsibility of communities, institutions and governments to ensure that their dignity and human rights are upheld, and they are helped in order to resume their normal lives again.

Published in SouthAsia Magazine,Aug 2007.

White

A short story

I have been sitting here for over an hour. She hasn’t looked up once. She hasn’t acknowledged my presence. She doesn’t recognize me. She can’t.

It is not easy to come to terms with. That real is not real anymore. That my world is not hers anymore. That she is not mine. Anymore.

A lone tear escapes her eye, and burns a trail down my cheek.

I’m tired. Of trying to make a sense of it all. And getting nowhere. Why, I wonder, does it have to be me? Or her? Or anyone at all?



This story is being edited. Watch this space!