14th December 1997


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It’s much more than safe sex

As the problem of AIDS rages on, NGO’s feel it is not just a health problem but a human rights issue.But there are those who believe that NGO’s are making a mountain out of a mole hill
By Farah Mihlar

Homosexuality is ille gal in Sri Lanka. It is also a major contributory factor to the spread of the Aids virus. As a result of the laws those who are infected with H.I.V through homosexual behaviour never come out into the open and claim it. “Its hard to reach out, we 6LABEL it ourselves, because our laws call homosexuals criminals and we talk about trying to avoid H.I.V. and the need to do something,” says The Director of Companions on a Journey, Sherman de Ros.

According to statistics released by the World Health Organization (WHO), 229 Aids cases have been detected in Sri Lanka. Available statistics show that almost 85% have contracted it through heterosexual behaviour. The accepted world figures are that 79% of those infected with Aids contracted it through sexual transmission. The figures imply there is something wrong in the statistical conclusions in Sri Lanka. Non Governmental Organizations (NGO’s) working in the field suggest this is because of the legal obstacles and social stigma homosexuals face in society. This prevents them from openly admitting they were infected with HIV because of their behaviour.

Preventing the spread of HIV is not just about safe sex, blood tests and disposable needles. It is more importantly about reforming the legal system to handle this problem. By the year 2000 there are expected to be an estimated 33000 positive HIV cases in Sri Lanka. They are going to be mainly from the country’s work force and if nothing is done to avert a possible crisis, not only will we be affected culturally and socially, but the country’s economy will also suffer.

Laws pertaining to abortions is another socalled loophole in the legal system. The present law bans abortions and it specifies that if it is done to save the life of the woman, the best interest of the unborn child must also be considered. If in Sri Lanka, an HIV positive mother whose immune system is virtually collapsing feels she is unfit to give birth to her baby and chooses to terminate the pregnancy, can she be prosecuted for not acting in the best interest of the child? There is only a mere 34% chance that the disease will spread from the mother to the child.

Such cases have not arisen in this country, but they will invariably in the future. Western states have already amended their laws to cope with the increasing spread of the Aids virus but despite WHO predictions that 90% of those infected with Aids will be from developing nations, countries like Sri Lanka have not given priority to legal reform.

“It is not just a health problem, it is a larger issue. It is a human rights issue,” says Rohan Edirisinghe Director of the Centre for Policy Alternatives (C.P.A.). He is amongst hundreds of others who are lobbying for legal changes to prevent the discrimination of Aids patients. The stories are pathetic. In a recent case in Elpitiya photocopies of a preliminary test result of an HIV positive patient were in the possession of every villager and the police attempted to arrest her to prevent infecting others. At a recent workshop a doctor who was infected with Aids spoke of how, when she was discharged from hospital, the matrons asked her never to come back for treatment.

The incidents of discrimination are limitless. Family members of Aids patients have been treated badly, children have been sacked from schools, their houses have been burnt down. They have been asked to leave their work places. Often the health authorities refuse to treat Aids patients. A few years ago a senior medical consultant was treated like a criminal, because he performed surgery on an Aids victim. The local attitude towards an Aids patient is to isolate them from society.

There are some who believe that the NGO’s are making a ‘mountain out of a mole hill.’ A senior official in the government’s Aids programme says “Its all talk” and that there are no real cases of discrimination any more. “We are not where we were 5 or 6 years ago, we are getting better”, says the official. This appears to be the minority view. Those like Mr. Edirisinghe only see the situation worsening and believe that legislation is needed to prevent the continuance of discrimination. “An HIV positive person has a death sentence but can work for 10-15 years”, he says emphasising the uniqueness of the disease which basically ensures normalcy, though it may not in fact be so. He also argues that unlike other contagious diseases, Aids is not spread through contact and therefore does not require a person to be treated differently. This is why discrimination must be prevented. “Should we prepare for this - the situation where a company sacks X who has Aids,” he says.

In a foreign country a woman sued her husband for infecting her with Aids knowing he was infected. Section 262/263 of the Penal Code refers to the criminal offence of infecting someone with a contagious disease. The legal provision reflects on the general public who also have a right not to be infected with the virus. There is conflict in the thought process. Is there an over emphasis on the human rights of the Aids patient? Then what about the rights of the others? “Individual rights does not mean people can do some wrong and claim individual rights,” says Mallika Ganesinghe a lawyer involved in the field. She explains that Aids patients can sometimes be vengeful and there is the possibility that they may purposely infect another. What can the law offer to such people and can the HIV positive person face criminal liability? she queries.

The general consensus however is that the rights of the patient is far superior. “The obligation is on the HIV free person to protect himself,” says Mr. Edirisinghe. He explains that if all people practice safe sex or stick to one partner and if the state takes over the responsibility of testing blood and maintains other medical standards, then the individual’s rights will automatically be protected.

Maintaining confidentiality is another gray area. Until recently a doctor treating an HIV positive person was required to notify the health authorities in the area, of the person’s identity and residence. This move came under severe criticism by human rights activists, and the requirement has finally been done away with . There is little doubt about the trauma an HIV positive case would have to suffer if there was a breach in confidentiality and for this reason it is accepted that maintaining confidentiality is vital. There is also no public health rationale in breaking confidentiality because HIV is not spread through casual contact, food, water, toilet or through insect bites. Even for statistical purposes it is only the mode of transmission that is needed and not other details like the name and location of the person.

However as much as the law is expected not to force a person to declare he has Aids there are some who argue that the law is also expected to prevent others from contracting the disease. The rare example is when a parent enters a child with Aids into a school. Legally the parent need not disclose the fact the child has Aids. However suppose the child has a biting habit and transmits the disease to another. Where does the law stand? Most officials who work with Aids patients emphasise these are hypothetical, remote cases and such conflicting views should not be encouraged as they could be detrimental to the correct stand on maintaining confidentiality.

“The policy of confidentiality which is human right friendly is also the most efficient”, explains Mr. Edirisinghe. He says requirements such as mandatory testing which would force certain individuals to be tested for HIV and breaches of confidentiality not only violate human rights but also create fear and tend to push people likely to be infected, “underground” and away from health care. If these two factors are non existent people would come forward for testing voluntarily which would result in the detection of more cases. Here too however there appears to be some conflict in views. For instance in a case where a paedophile who is believed to have abused at least 40 children, dies of Aids can the abused victims be forced to take a test?

These cases may be rare but questions have arisen as to the role of a magistrate or a district judge - can he order a child to be tested in a situation where the parents do not consent to testing? Similarly if a convicted rapist is found to have Aids, would it be necessary to test his victims? The NGO’s fear that if mandatory testing is legally permitted, then one cannot draw the line. The authorities will be permitted to request any person suspected of having HIV to be tested. The ultimate result would be that fewer people will come out in the open and it would become impossible to control the spread of the disease.

There is also a need to introduce legislation to protect the rights of women. In Africa there was a case where a man filed for divorce because his wife had contracted Aids while his test result, read negative.

He brought forward the argument that she had committed adultery on that basis and was successful in the divorce appeal. Later however his results showed he too was HIV positive and his wife had been infected by him. Research has shown that in Sri Lanka the family unit remains strong in cases where one member contracts HIV and in most cases spouses have shown tremendous support. But women’s groups here argue that legislation is still necessary to avoid mishaps.

There is an urgent need to resolve the conflicting views that exist today, if not in the near future, at least before the estimated 33000 HIV positive cases by the year 2000 becomes a reality. “It is a unique disease and needs a unique response,” says Edirisinghe!

NGO’s feel left out

Several NGOs recently presented a set of recommendations for legal reform to deal with the spread of the AIDS virus, but since the recommendations were made nothing has happened. The recommendations were put forward under 3 categories firstly under clinical response, secondly under HIV testing and thirdly under the yheme of the state’s response to HIV positive cases and their families. Under these recommendations far reaching proposals have been made with regard to preventing discrimination.

Great emphasis has also been laid on the introduction of laws to make public health workers more responsible. The WHO suggests that to prevent the spread of Aids, countries adopt what is called universal health precautions. Under this system every one in the medical field treats all patients as if the person may be infected by HIV. The UNDEP in a study pertaining to Sri Lanka has announced that the country does not have the resources nor the finances to adopt such measures. NGOs however insist that if the policy is not to be introduced in Sri Lanka, then some legal provisions must exist to hold those in the medical fields responsible for the prevention of the virus spreading.

The problem in dealing with HIV in this country is that the conflicting views exist and questions remain unanswered because there is no common forum to discuss the issues. NGO workers say they are never included in the decision making process, which is solely treated as a health issue. “The people who work at grassroots level were not given the opportunity. We know how people feel but they just call the people who sit behind their desks,” says Mr. Ganasinghe.

This is the constant complaint expressed by those in the field. A few months ago the Health Ministry drew up a plan to tackle the spread of HIV in the next two years. The NGOs claim they were not allowed to participate in the deliberations and therefore were detached from the policy decisions. Health Ministry officials argue that all NGOs cannot be represented on such occasions adding that two representatives of the GO advisory committee were represented in the National Aids Committee which is ultimately responsible for the formulation of laws. It appears to be a weak argument. “There are 260 NGOs who work on HIV cases in Sri Lanka and they were not even considered ,” says de Ros, on the other hand. - FM

Now, you don’t have to fear ulcers

Millions of people with stomach ul cers go undiagnosed and untreated, because neither they nor their physicians know that most ulcers are caused by a common and easily treated bacterial infection, according to a new U.S. government survey.

The survey, which was conducted by the U.S. Centre for Disease Control and Prevention, found that very few people understand that a bacterial infection is responsible for stomach ulcers. Many erroneously believe that most stomach ulcers are caused by a combination of stress and eating spicy food.

“For years, we all thought ulcers were a chronic condition ..and had to be endured for the rest of our lives,” says Mitchell L. Cohen, director of the CDC’s Division of Bacterial and Mycotic Diseases. “That isn’t true. Most ulcers are caused by a bacterial infection, and even if you’ve had an ulcer for years, you could still be cured.” The cost of ulcer complications is enormous - running at an estimated $6 billion a year for medical bills and lost days from work, according to thc CDC. Yet, studies show that more than 90 per cent of ulcers are caused by an infection with a spiral-shaped bacterium, known as Helicobacter pylori (H. pylori), which is easily treated with a two-week course of antibiotics.

Ulcers are small holes or sores that form in the lining of the stomach, or in the first section of the intestine known as the duodenum. Left untreated, they can cause serious gastrointestinal bleeding. About 40,000 people undergo emergency surgery and 6,000 die annually in the United States from complications of peptic ulcers. There is also growing evidence that chronic, untreated ulcers may increase the risk of stomach cancer.

Early evidence, linking stomach ulcers to infection with H. pylori, emerged in 1982 from work by Australian physicians Robin Warren and Barry Marshall. The idea that a simple bacterial infection caused ulcers was controversial within the medical community. But Marshall was so convinced of the link between H. pylori and ulcers that he ingested the bacteria documented both the formation of his own stomach ulcers and their cure, following treatment with a combination of antibiotics and stomach-acid neutralising medicines.

The US National Institute of Health convened an expert panel to review ulcer treatment in 1994. Until that time, standard therapy relied primarily on drugs called H-2 blockers, named because they interfere with the release of histamine in the body and thus thwart acid production in the stomach. The NIH consensus panel concluded that the link was strong enough between H. pylori and ulcers to recommend that ulcer patients, infected with the bacteria, undergo treatment with antibiotics.

Nonetheless, the idea has been slow to catch on, and in 1995, the CDC found that only 5 per cent of ulcer patients were being treated with antibiotics. These statistics prompted the CDC to team with the National Institute of Health - and other government agencies and industry groups to launch a public-awareness campaign in the U.S about the link between H. pylori infection and stomach ulcers. The goal is to improve early diagnosis and treatment of ulcers, says Cohen.

The campaign targets adults in their mid-30s, who may not recognise the early symptoms of ulcer disease, and adults aged 60 and older, who are long term ulcer patients and are suffering needlessly because they have not received the new antibiotic therapy. Till recently, testing for H. pylori was a complicated, invasive procedure. But new techniques make it possible to detect the infection by drawing a small amount of blood, or by giving patients simple breath test, says Benjamin D. - FRIDAY

The maiden years are over

Jemima Khan reveals what she has learned about motherhood while living with husband Imran’s extended family in Pakistan

Two years ago, when 21-year- old Jemima Goldsmith married Pakistani cricketing hero Imran Khan, 42, many people thought she would soon come to regret the sacrifices she would have to make in order to be a dutiful wife in a Muslim country. But while there have been adjustments to make, Jemima now the mother of a one-year-old son Sulaiman, is adamant that she has gained far more than she has lost by embracing another culture.

“Before I moved to Pakistan I assumed that leaving home was a necessary part of growing up. However, having lived for two years since my marriage as part of an extended family in a traditional society. I now believe the joint family system and small intimate communities form a more solid foundation for the development of mature and stable individuals.

“As my child grows up surrounded by all his young cousins, I have come to realise that the most obvious advantage of living in Pakistan is being part of a society that encourages mutual interdependence and close social and family ties.”

It is a lesson she applies now when she brings Sulaiman back to Britain for visits. “I choose to live with my mother in our family home in Richmond rather than in a separate central London apartment, primarily because I now understand the importance of the special bond that can develop between grandparent and child.”

The pattern that has been established in the West of separating the generations, is she says, not only a sad one but a wasteful one, too, “In Pakistan, it is unthinkable even to consider putting one’s parents in a ‘home’ or to assume , as many now do in the West, that the elderly are the state’s responsibility. An individual who fails to take care of a parent or grandparent becomes a virtual pariah.”

But it’s not just the fear of disapproval that leads Pakistani families to honour and include their older generations. “Children benefit from close contact with grandparents,” believes Jemima. “My son spends hours playing in his grandfather’s room in Pakistan, enjoying the special indulgences denied by parents. Once a week Aga Jan (a respectful term for an elder in the family) takes all his grandchildren for their communal Friday prayers in the mosque and there is great excitement - which seems to me touchingly old-fashioned - as they prepare to leave the house in their smartest Friday clothes.”

Jemima says that as Sulaiman grows up and she sees how much he needs constant mental and physical stimulation, she sympathises with the plight of single working mothers. “They are forced to send their children into day -care, where they can receive only the most superficial attention. It is not the single mother who should be condemned, as so often happens, but the society in which a woman without a husband to rely on often has no other family or financial support to fall back on.”

While outsiders stress the restrictions put on Muslim women Jemima is now more aware of the freedoms a traditional society can bestow. “In Imran’s family one of my sisters-in-law, who has four children, works part time as a surgeon. During her working hours, the children are left in the familiar environment of their home with a whole range of relatives to care for them.”

“Society revolves around family life which allows mothers and children to be together at all times. When people gather to discuss important issues or attend festivals or parties, even late at night , children are always present. When I’m in England I long to take my child along to dinner with me, but sadly it’s not practical and it’s just not done”.

She also recounts with amusement the horror of her British friends to some of the choices she has made. “In Pakistan, most mothers breast feed for about two years, which surprises most foreigners who seem to feel this is unnatural behaviour. I remember in a moment of exhausted defeatism I told one of my girlfriends that I was going to give up feeding. She breathed an audible sigh of relief and exclaimed, ‘Thank God, we all thought you would be one of those fanatics who would be breast feeding until your child was walking. Thankfully, I managed to re-energise myself and it seems her fears were well-founded!”

“The habit of feeding cow’s milk to a baby from a plastic bottle on strict schedule would be incomprehensible to most Pakistanis.”

Although she came to Britain for the delivery of her baby she found on her return to Pakistan that she was glad to be able to throw out some of the Western strictures on baby-rearing. “I used to hold my hands over my ears as he cried thinking he would feed better if I gradually forced him into a four hour pattern. My sister -in-law was astonished .

“Why do you torture yourself and him?” she asked.

“In many ways, we are encouraged in the West to act against our most natural instincts. Mothering has been made to seem so scientific that one hardly has the confidence to trust one’s own instincts any more.”

In a society where mothering is still largely left to mothers, without advice from “experts” she found less guilt and anxiety in families.

“When my sister-in-law told me how one of her children did not begin speaking before the age of three I was shocked, recalls Jemima, “ and asked if she had not been at all concerned. She just laughed and said. ‘Children will progress at their own rate.”

“Individuals and children in particular, appear less emotionally dependent in the joint family system since they are in close and continual contact with so many other people of all ages, from babies to great grandparents, and have sufficient emotional and psychological security to become independent.

“Within this framework of support, no one relationship has to bear too much emotional intensity or weight of responsibility. As a result there seems to be none of that needy attachment and insecurity characteristic of Western family relationships.

“When a child is given unconditional and unlimited love by all round him, far from being ‘spoilt’ as we would say in the West, I have found that he is in fact far freer, less demanding and more content; he learns sooner and more readily to take responsibility for someone else.” – Hello

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