Improving LGBT Health Education in South Africa: Addressing the Gap

I first became interested in the topic of lesbian, gay, bisexual, and transgender (LGBT) health care and health education while working as a country lead for the Presidential Emergency Plan for AIDS Relief (PEPFAR). During my time there I had the opportunity to travel to South Africa and understand their community and health care system a bit better, with an emphasis on their HIV/AIDS epidemic. This post focuses on the LGBT history in South Africa, recent developments, addressing that there is a gap between homophobia and non-judgmental care, and the importance of health care workers understanding LGBT health education.

More and more countries around the world are opening their arms to welcome and embrace LGBT pride. South Africa has one of the world’s more progressive constitutions which legally protects LGBT people from discrimination, although current research indicates that they continue to face discrimination and homophobia in many different facets of life. The most recent milestone occurred in 2006 when the country passed a law to recognize same-sex marriages. Nevertheless, LGBT South Africans particularly those outside of the major cities, continue to face some challenges including conservative attitudes, violence, and high rates of disease. As the country continues to grow there seems to be an increase in LGBT representation (with approximately 4,900,000 people identifying as LGBT) whether it is through activism, tourism, the media and society or support from religious groups. So, what about LGBT health education? Continue reading “Improving LGBT Health Education in South Africa: Addressing the Gap”

Advertisements

Policy on #HIV related travel restrictions adopted by @WFPHA_FMASP at #WCPH2017 now posted

After APHA adopted its permanent policy statement on HIV-related immigration restrictions that we submitted at last year’s Annual Meeting, the IH Section worked with APHA’s WFPHA liaison, Dr. Deborah Klein-Walker, to submit a corresponding policy proposal on behalf of APHA to the World Federation of Public Health Associations, which held its 15th World Congress on Public Health this month in Melbourne, Australia. The proposal was accepted and passed by the WFPHA Policy Committee at the meeting, and has now been posted the website (PDF). The text of the policy (excluding references) is below.

Scientific evidence and treatment needed to combat the spread of HIV – not ineffective travel bans

Submitted by the American Public Health Association
(Contact person D. Walker)

Introduction
HIV-related restrictions against entry, stay, and residence remain common around the world. Various countries have policies that mandate HIV testing of all or certain groups of foreign nationals as a condition of obtaining a visa for employment. These policies have no basis in science and violate migrant workers’ human rights to confidentiality and informed consent to testing, exposing them to exploitation by their employers. According to UNAIDS, 35 countries currently have official HIV-related travel restrictions. Furthermore, HIV-related travel restrictions against foreign nationals have been shown by international treaty bodies, international legal scholars, and human rights organizations to constitute discrimination based on race, ethnicity, and/or country of origin.

Scope and Purpose
Restrictions on travel, immigration, or residence related to HIV status are a violation of the principles of nondiscrimination and equal treatment in all international human rights laws, treaties, and agreements. The International Covenant on Civil and Political Rights guarantees the right to equal protection under the law, free from discrimination based on race, color, sex, language, religion, political or other opinion, national or social origin, property, birth, or other status, and the UN Commission on Human Rights has determined that this includes discrimination based on health status, including HIV infection. According to the Siracusa Principles on the Limitation and Derogation Provisions in the International Covenant on Civil and Political Rights, while international human rights law allows governments to restrict rights in cases of emergency or serious public concern, the restrictions must be the minimum necessary to effectively address the concern – and HIV-related travel restrictions have been overwhelmingly ruled as both overly intrusive and ineffective public health policy. Within such restrictions, compulsory HIV testing is a serious violation of numerous human rights principles, including the right to bodily integrity and dignity. The accompanying deportation and/or loss of employment and residency status of HIV-infected migrants that frequently accompanies such testing violates the rights of PLWHA to privacy, work, and appropriate medical care. The International Labour Organization (ILO) has specifically stated that neither HIV tests nor private HIV-related personal information should be required of employees or job applicants.

Despite this robust evidence base, according to UNAIDS, 35 countries currently have official HIV-related travel restrictions openly acknowledged and enforced by the government. These restrictions vary from outright entry bans, which bar PLWHA from entering the country, to restrictions on stays longer than a specified period of time or to obtain employment visas or residency status. Others have inconsistent policies and/or intentionally misrepresent their policies with HIV-related restrictions. Such policies and practices, and the number of migrants impacted by them, are difficult to track because of differing or ambiguous definitions and a lack of data. Some of the most restrictive policies subject immigrants to mandatory HIV testing, either when applying for residency or for an employment visa, which is frequently required by states for legal residency.

The two primary justifications provided by governments for mandatory HIV tests for migrant workers and other HIV-related travel restrictions are to protect public health and reduce the cost burden on the country’s healthcare system imposed by providing HIV care services to foreign nationals. While countries have the right to employ measures to protect their populations from communicable diseases of public health concern, HIV is not transmitted by casual contact, meaning there is no scientific basis for attempting to control its spread via immigration policies. Furthermore, countries that do not have HIV-related travel restrictions have not reported any negative public health consequences compared to those that do, and recent analysis suggests that even migration from countries with generalized HIV epidemics does not pose a public health risk to destination countries.

In fact, immigration policies banning or restricting entry or employment based on HIV status often have the opposite effect of their protective intention, causing direct harm to the health of both of immigrants and citizens. They marginalize PLWHA, regularly discourage people from accessing HIV testing and treatment, and reinforce stereotypes and discriminatory attitudes against PLWHA in the general population. Regulations requiring HIV tests of immigrants can promote the idea that foreigners are dangerous to the national population and a public health risk, as well as creating a false sense of security by reinforcing the notion that only migrants are at risk for infection. Additionally, such attitudes can adversely impact the host country’s own HIV epidemic, as citizens who are unaware of their HIV-positive status, underestimating their own HIV risk and avoiding testing due to stigmatization, are more likely to transmit the virus to others, driving up infection rates.

State-enforced HIV screening of migrants costs far more than it saves in treatment costs. Screening travelers and migrants for HIV is impractical and expensive.[5][13][19] Labor migrants (both regular and undocumented) bring significant economic benefits to their host countries, in addition to themselves, and this cost-benefit balance remains even when migrants are HIV-positive and rely on the host country’s health care system for treatment and support.

Fields of Application:

  • National public health associations and their members
  • Human rights and HIV advocacy groups
  • UNAIDS
  • The World Federation of Public Health Associations

Action Steps:

The WFPHA joins with UNAIDS, the World Health Assembly, and other HIV and human rights organizations (e.g., Amnesty International, Human Rights Watch, ILO) to call on all countries that still maintain and/or enforce HIV-related restrictions on entry, stay, or residence to eliminate such restrictions, ensuring that all HIV testing is confidential and voluntary and that counseling and medical care be available to all PLWHA within its borders, including migrants and foreign nationals.

The WFPHA affirms the following principles:

  • All people have the right to confidential and voluntary HIV testing and counseling.
  • Persons living with HIV/AIDS (PLWHA) have the right to privacy, to work, and to appropriate medical care.
  • All HIV-related travel and immigration restrictions currently in place should be removed.
  • Agencies and businesses who employ foreign nationals should not use HIV tests as a means to discriminate against potential employees.
  • Governments should provide HIV prevention and treatment services that are equally accessible to citizens and foreign nationals.
  • Migrant workers should have access to culturally appropriate HIV prevention and care programs in languages that they can understand.

The WFPHA recommends that:

  1. Public health associations in every country should:
    1. Develop policies opposing HIV-related travel restrictions;
    2. Document and/or support human rights and HIV advocacy groups in documenting immigration policies that explicitly discriminate, or allow employers to discriminate, against migrants based on HIV status;
    3. Document and/or support human rights and HIV advocacy groups in documenting any HIV testing practices that are not voluntary or confidential;
    4. Inform their members and the public that HIV-related travel restrictions and compulsory HIV testing of foreign nationals is a violation of human rights and does not protect public health or reduce health care costs; and
    5. Advocate for the removal of any and all HIV-related travel restrictions enforced or condoned by their country governments.
  2. UNAIDS should take steps to ensure that its protocols to research and investigate countries’ HIV-related travel restrictions are sufficiently thorough by monitoring and documenting any reported instances of HIV-related discrimination targeting immigrants, particularly when presented with evidence demonstrating that recognition of a country’s removal of HIV-related travel restrictions is unwarranted, in order to ensure that governments are not able to misrepresent their policies in order to gain undeserved recognition for supporting human rights with regard to HIV/AIDS.

WFPHA supports the removal of all HIV-related travel restrictions and travel related mandatory testing.

Too far to go still: India’s struggle against gang-rape continues

This was cross-posted to my professional blog.

In the worst news you’ll read today, yet another gang-rape – of another tourist, and the second one this week – has surfaced in India.

An 18-year-old German was allegedly raped on Friday after falling asleep on a train heading to Chennai in southeastern India, where she was going to do volunteer work with a charity.

“The young lady took several days to muster courage to report to the police,” Inspector General of Police Seema Agarwal told NDTV. “Though it’s too late for medical examination, we have handled the case in a very sensitive manner.”

The attack brings the toll of publicized rapes on foreigners in the country to two in just a week, after a 51-year-old Danish woman was allegedly gang-raped in New Delhi on Tuesday.

En route to do charity work – they say no good deed goes unpunished, but damn.

Rape in general, and gang-rape in particular, has been the subject of a lot of scrutiny, and (thankfully) a whole lot of national soul-searching in India since the report of a brutal gang-rape on a bus in New Delhi made international headlines in 2012. Naturally, the stories involving tourists tend to garner more attention that those of locals, but there have been plenty of those to go around. Take the case of the German tourist raped by her yoga instructor in December. Or the British woman who jumped from her hotel window to escape a rape by the hotel manager. Or the Swiss woman who was brutalized by five tribesmen while her husband was tied to a tree. All of these news article mention, and often link to, stories of multiple other women who went through similar ordeals. You could spend all day following the links and questioning the humanity of humanity, or seriously wondering if Antoine Dodson had it right after all.

In response to the 2012 Delhi case and subsequent uproar, the Indian government worked very quickly to strengthen existing rape laws and increase punishments for perpetrators. However, while cases involving foreigners are seen through, too many cases reported by Indian women are just dropped, or completely ignored. Meanwhile, no one can really explain why this keeps happening.

A few obvious things spring to mind. Feminists in the west wage a never-ending battle against rape culture and victim-blaming, but the terms take on a whole new light in Indian culture, which is dominated by men and dictated by strict social rules. In the Delhi case, the defendants’ lawyer offered this gem to the press:

“Until today I have not seen a single incident or example of rape with a respected lady,” Sharma said in an interview at a cafe outside the Supreme Court in India’s capital. “Even an underworld don would not like to touch a girl with respect.”

Sharma said the man and woman should not have been traveling back late in the evening and making their journey on public transport. He also it was the man’s responsibility to protect the woman and that he had failed in his duty.

“The man has broken the faith of the woman,” Sharma said. “If a man fails to protect the woman, or she has a single doubt about his failure to protect her, the woman will never go with that man.”

A spiritual guru and a politician offered a different perspectives:

A spiritual guru, Asharam, sparked an outcry earlier this week when he said the New Delhi victim was equally responsible and should have “chanted God’s name and fallen at the feet of the attackers” to stop the assault.

Mohan Bhagwat, the head of the pro-Hindu Rashtriya Swayamsevak Sangh that underpins the country’s main opposition political party, said rapes only occur in Indian cities, not in its villages, because women there adopt western lifestyles.

Pearls of wisdom, to be sure.

One factoid that has been indicated is the stark gender imbalance, propagated by sex-selective abortions and female infanticide. Another issue is the widespread prevalence of abject poverty; the perpetrators are bored, desensitized, and have nothing to lose. An October article in the New York Times examined the issue in depth through coverage of a case in Mumbai:

One problem is that perpetrators may not view their actions as a grave crime, but something closer to mischief. A survey of more than 10,000 men carried out in six Asian countries — India not among them — and published in The Lancet Global Health journal in September came up with startling data. It found that, when the word “rape” was not used as part of a questionnaire, more than one in 10 men in the region admitted to forcing sex on a woman who was not their partner.

Asked why, 73 percent said the reason was “entitlement.” Fifty-nine percent said their motivation was “entertainment seeking,” agreeing with the statements “I wanted to have fun” or “I was bored.” Flavia Agnes, a Mumbai women’s rights lawyer who has been working on rape cases since the 1970s, said the findings rang true to her experience.

“It’s just frivolous; they just do it casually,” she said. “There is so much abject poverty. They just want to have a little fun on the side. That’s it. See, they have nothing to lose.”

Child marriage (finally) seen as a health issue (in addition to one of human rights)

This was cross-posted to my new professional blog.

As someone who takes particular interest in the intersection of health and human rights, I am glad to see this issue gaining the attention at the crossroads it deserves. Child marriage, which has been covered in recent years by such high-profile publications as National Geographic, has long been decried a human rights violation of young girls around the world. It garnered special attention with the story of Nujood Ali, an extraordinary young Yemeni girl who, after being married off at age ten to a man three times her age, escaped to a courthouse and demanded a divorce. She published her memoirs in 2009, which put the Middle East in the spotlight for the problem, but child marriage happens all around the world – and, in the case of Haiti, much closer to home than we Americans usually tend to think. Now, as my colleague Tom Murphy has pointed out on Humanosphere, child marriage is beginning to receive the attention it needs from the global health side as well.

Long considered an issue of human rights, the conversation about child marriage is shifting to that of health and education. Girls married too young are denied the educational opportunities of their peers and are put at greater health risks, such as HIV and teen pregnancy.

What may seem like a distant problem, child marriage is found in every part of the world. Ending the global practice will unleash opportunity for millions of women and girls.

(Side note: I promise that Humanosphere is not the only global health blog I follow, but I find it to be one of the most informative and well-rounded, so I link back to it a lot. Perhaps I need to lengthen my blogroll.)

At a glance, it’s easy enough to see both the health and the human rights problems with child marriages. First and foremost, the girls are married against their will, or without full knowledge of what it happening to them. Many of the girls are raped and abused; a few high-profile cases have featured girls who died of internal bleeding or fistula after their “husbands” finished with them. Teenage pregnancy, being cut off from education, perpetuating poverty cycles. The list goes on and on.

Unfortunately, it is just as easy to see that the solutions are not so simple; as the National Geographic feature points out, we cannot just “rescue” the girls by carrying them off into the sunset, as Nick Kristoff occasionally does. The reasons for these traditions are culturally ingrained and have to be addressed at the community level.

Efforts to reduce this number are mindful of the varied forces pushing a teenager to marry and begin childbearing, thus killing her chances at more education and decent wages. Coercion doesn’t always come in the form of domineering parents. Sometimes girls bail out on their childhoods because it’s expected of them or because their communities have nothing else to offer. What seems to work best, when marriage-delaying programs do take hold, is local incentive rather than castigation: direct inducements to keep girls in school, along with schools they can realistically attend. India trains village health workers called sathins, who monitor the well-being of area families; their duties include reminding villagers that child marriage is not only a crime but also a profound harm to their daughters.

Global Health Weekly News Round-Up

UNICEF celebrated its 65th anniversary on December 11, 2011 (Source: http://www.unicefusa.org/news/news-from-the-field/unicef-at-65-looking-back.html).

Politics and Policies

  • The US Department of Health and Human Services announced that, beginning in 2014, states will be allowed a basic set of essential health benefits for millions of Americans who would qualify for coverage through state based insurance exchanges (Source: http://www.politicalnewsnow.com/2011/12/17/states-to-weigh-in-on-basic-health-coverage-reuters/).
  • The US National Transportation and Safety Board (NTSB) called for the first ever nation-wide ban on drive use of portable electronic devices (PEDs) while operating a motor vehicle (Source: http://www.ntsb.gov/news/2011/111213.html).
  • The Association of American Physicians and Surgeons (AAPS) have opposed a rule that required the health care facilities workers to have an annual influenza vaccine or they lose their jobs (Source: http://www.reuters.com/article/2011/12/14/idUS205180+14-Dec-2011+GNW20111214).
  • First United Nations (UN) report on human rights, sexual orientation and gender identity, titled, “Discriminatory laws and practices and acts of violence against individuals based on their sexual orientation and gender identity, A.HRC.19.41.” was released on Wednesday, December 15th, 2011 (Source: http://www.windycitymediagroup.com/gay/lesbian/news/ARTICLE.php?AID=35274).
  • The United States Conference of Mayors issued a report indicating emergency food assistance increased over the past year by an average of 15%. This report, prepared by City Policy Associates, contains each city (29 cities) survey report with their individual profiles – median household income, the metro unemployment rate, the monthly foreclosure rate, percentage of people in city who fall below the poverty line and contact information for individual service providers (Source: http://www.usmayors.org/pressreleases/uploads/20111215-release-hhr-en.pdf).

Programs

Research

Diseases and Disasters

These headlines were compiled by Vani Nanda, MPH Candidate at West Chester University PA.