http://www.irinnews.org/irin-fp.aspxUpdated everydayen-gbFri, 20 Nov 2009 08:54:05 GMTNAIROBI Friday, November 20, 2009 (IRIN) - HIV-positive women in western Uganda want fewer children than women not living with the virus, but often do not have access to family planning services, a new study reveals. NAIROBI Friday, November 20, 2009 (IRIN) - HIV-positive women in western Uganda want fewer children than women not living with the virus, but often do not have access to family planning services, a new study reveals.

The study of 421 women in the district of Kabarole found that the probability of HIV-positive women wanting to stop childbearing was 6.25 times greater than it was for HIV-negative individuals.

“HIV-positive women tended to want fewer children than their HIV-negative counterparts mainly because they are aware of the risks of mother-to-child transmission and do not want to go through the difficulties associated with having an HIV-positive child,” said Walter Kipp, global health professor at the University of Alberta in Canada, and one of the study’s authors.

Statistics from the UN Children’s Fund http://www.scribd.com/doc/20951464/PMTCT show that in 2008, only 55 percent of HIV-positive pregnant women received antiretroviral treatment to prevent mother-to-child transmission; close to 30,000 Ugandan children are infected with HIV at birth every year.

Kipp noted that the survey’s results highlight the urgent need to integrate family planning into HIV services. “Family planning in Uganda is not well developed, and if women want to stop having children, often they have no access to contraceptive pills or other family planning methods,” he said.

According to the Ministry of Health, 41 percent of Ugandan women who would like to stop having children have no access to family planning services. The country has the third-highest population growth rate in the world; only Yemen and Niger have higher rates.

Kipp noted there was a need to harmonize the messages of family planning groups, which tended to recommend the use of hormonal contraception over condoms for contraception, and HIV groups, which emphasized condom use for prevention.

“For HIV-positive women, we would usually recommend dual protection, which is the use of both a hormonal contraceptive and condoms,” he added.

A recent analysis http://journals.lww.com/aidsonline/Abstract/2009/11001/Benefits_and_costs_of_expanding_access_to_family.14.aspx published in the Journal of the International AIDS Society found that family planning was cost-effective for preventing HIV transmission and unintended pregnancies and would also reduce infant and maternal mortality and result in fewer orphans.

The survey noted there was a need for education to inform the population on the benefits of family planning and end misconceptions around the subject.

“There is a belief that hormonal contraception can affect future fertility, and that it may lead to malformed children in the future,” Kipp said. “However, the main barrier that needs to be overcome is the lack of availability of these services for women who need them.”

kr/oa/mwhttp://www.irinnews.org/report.aspx?ReportId=87125SIAYA Thursday, November 19, 2009 (IRIN) - When Dorothy*, a single mother of five, told her neighbours in the Kenyan capital, Nairobi, she had tuberculosis (TB), she expected sympathy and maybe even offers of help. Instead, she found herself so severely ostracized, she felt she had to move out.SIAYA Thursday, November 19, 2009 (IRIN) - When Dorothy*, a single mother of five, told her neighbours in the Kenyan capital, Nairobi, she had tuberculosis (TB), she expected sympathy and maybe even offers of help. Instead, she found herself so severely ostracized, she felt she had to move out.

"The kind of discrimination I faced from my neighbours made me regret [sharing] my condition with them; I could not even share the [communal] sink," she told IRIN/PlusNews. "Yes, tuberculosis is very infectious, but those who have it are not death traps."

According to Joseph Sitienei, head of the National Leprosy and TB Control Programme at the Ministry of Health, stigma associated with TB infection is a major impediment in rallying people to seek early diagnosis and treatment for the airborne disease.

"Many people still believe only those with HIV have tuberculosis and therefore they shy away from seeking diagnostic tests for TB, believing if they are found to have it, then it automatically means they are also HIV-positive," he told IRIN/PlusNews. "By those infected not seeking treatment due to stigma, everybody is at great risk."

Dropping out of treatment heightens the risk of multi-drug resistant TB (MDR-TB) developing, "which is very expensive and difficult to treat", Sitienei added. Kenya has 353 people with MDR-TB, of whom about 70 are on treatment.

According to the Kenya AIDS Indicator Survey, 11.4 percent of Kenyans say they would want a family member's TB infection kept secret due to stigma.

Kenya ranks 13th on the UN World Health Organization's list of 22 high-burden TB countries in the world, and is the fifth highest in Africa. In 2008, the country had approximately 132,000 new cases.

Research conducted in Ghana in 2008 found some of the main causes of TB-related stigma were: fear of infection; TB's association with HIV; health staff's own fears; self-stigmatization by TB patients; and the blaming and shaming of TB patients by the public.

While Kenya has successfully integrated HIV and TB services at the testing level, TB counselling still trails behind counselling for HIV.

Education is key

"We have done well in offering HIV testing and counselling and diagnosis of TB, but not much has happened in trying to offer counselling services to people with TB," said Nicholas Muraguri, head of the National AIDS and Sexually Transmitted Infections Control Programme. "This is crucial and possible because it can easily be done within the voluntary testing and counselling facilities."

According to Sitienei, public education about TB is crucial to provide a better understanding of the disease and improve health-seeking behaviour: "With proper counselling, people are better placed to understand their own situation and that of others," he said.

"The truth is, TB spreads very fast, but it is important to help people relate to those with TB without themselves having to fear putting themselves at risk," said Charles Mutua, a former TB patient.

"People must also be made to appreciate that TB infection is not necessarily synonymous with HIV infection. I, for example, had TB but I was never HIV infected," he added.

According to Andrew Suleh, superintendent of Nairobi's Mbagathi District Hospital, communication messages should include debunking popular myths – such as the idea that the disease can be transmitted by sharing utensils.

Ending health worker stigma

Sitienei said it was also important for health workers to understand the disease and treat patients with respect. In 2008, the government launched a communication campaign to reduce discrimination and stigma about HIV and TB among health workers.

"At times even the attitude among healthcare workers determines whether people seek services or not, even though our medical personnel are very conscious about issues of stigma," he said. "Addressing stigma involves fighting it among the public, health workers and those who are infected with TB."

Suleh noted that ensuring health workers were properly equipped to treat TB would help reduce stigmatization of patients.

"[Health worker stigma and discrimination] can arise when healthcare workers feel they are not given the adequate equipment or facilities to handle such cases," he said.

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* Not her real name

http://www.irinnews.org/report.aspx?ReportId=87108DUBAI Wednesday, November 18, 2009 (IRIN) - More people have died from H1N1 influenza in Iran than in any of the 22 countries in the World Health Organization (WHO) Eastern Mediterranean Region, according to WHO’s 14 November update.DUBAI Wednesday, November 18, 2009 (IRIN) - More people have died from H1N1 influenza in Iran than in any of the 22 countries in the World Health Organization (WHO) Eastern Mediterranean Region, according to WHO’s 14 November update.

With 33 deaths to date, Iran made up about 17 percent of the 188 total deaths in the region since May 2009. Saudi Arabia has had 28 deaths, Oman 25 and Syria 22.

Syria had by far the highest rate of deaths to cases with 9.5 percent of all cases being fatalities. This was followed by Yemen with a 2.5 percent rate, Afghanistan 1.7 percent and Iran 1.5 percent.

Kuwait had the highest number of cases with 6,640 (23 percent of all 28,751 cases in the region), followed by Saudi Arabia with 4,119; Oman 3,829; and Egypt 2,494.

Kuwait also had the highest number of cases per capita (populations taken from CIA Factbook) with 2.46 cases per 1,000 in the population, followed by Oman with 1.12 cases per 1,000 and Bahrain with 1.10 cases per 1,000.

Since WHO’s last regional H1N1 update on 7 November, Egypt has had the highest number of new cases, with 850, followed by Iraq with 561, Iran with 515 and Oman with 500.

Somalia reported its first two cases at the start of November.

As of 8 November, WHO reported that there were over 503,536 global cases of H1N1 with at least 6,260 deaths. However, it noted that because countries are “no longer required to test and report individual cases, the number of cases reported actually understates the real number of cases”.

WHO segments the world into six regions: Africa, the least affected region, had 2.9 percent of the global total of H1N1 cases; the Eastern Mediterranean Region 5.1 percent; Southeast Asia 8.8 percent; Europe 15.5 percent; the Western Pacific 29.8 percent and the Americas 37.9 percent.

BOX
Country Total laboratory-confirmed cases reported by the state parties Total deaths reported by the state parties
Afghanistan 779 14
Bahrain 793 6
Djibouti 9 0
Egypt 2,494 7
Iraq 1,835 9
Iran 2,153 33
Jordan 2,380 4
Kuwait 6,640 17
Lebanon 761 2
Libya 21 0
Morocco 824 0
Oman 3,829 25
Pakistan 6 1
Palestine 901 1
Qatar 23 1
Saudi Arabia 4,119 28
Somalia 2 0
Sudan 21 0
Syrian Arab Republic 230 22
Tunisia 141 0
United Arab Emirates 79 0
Yemen 711 18
Total 28,751 188

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http://www.irinnews.org/report.aspx?ReportId=87092KISUMU Tuesday, November 17, 2009 (IRIN) - The Kenyan government is expanding services to meet the growing demand for voluntary medical male circumcision after the launch of a national campaign a year ago.KISUMU Tuesday, November 17, 2009 (IRIN) - The Kenyan government is expanding services to meet the growing demand for voluntary medical male circumcision after the launch of a national campaign a year ago.

"We believe the launch of a rapid results initiative to scale up what we are already offering will help meet the demand; our target is an ambitious one to see to it that at least 1.1 million of the uncircumcised men in this country get the cut by the end of five years," said Jackson Kioko, director of medical services in western Nyanza Province.

Results of three random trials in South Africa, Kenya and Uganda in 2005 and 2006 demonstrated that medical male circumcision http://www.plusnews.org/InDepthMain.aspx?InDepthId=61&ReportId=73184 reduced the risk of HIV infection among men by up to 60 percent.

According to the Kenya AIDS Indicator Survey 2007, 85 percent of Kenyan men are circumcised; HIV prevalence is higher by three-to-five times in uncircumcised men. There are about 1.2 million uncircumcised men between the ages of 15 and 49 in Kenya, most of whom live in Nyanza Province, where fewer than 50 percent of men are circumcised.

Since the launch of the national campaign in November 2008, an estimated 40,000 men have been circumcised and 124 sites opened and equipped with facilities and personnel to offer the service. The government has trained 700 health workers in the province to offer the services in various health facilities.

"The trained health workers will ensure people who demand these services get them in a safe and timely manner and the training of others is ongoing across the various provinces within the country," Kioko added.

The government also plans to roll out mobile medical circumcision. "We do not want people to opt out simply because the services are not near them and we are making arrangements that we go to them rather than them coming to us," Kioko said. "We will, in the near future, offer infant medical circumcision; this has the potential to help people in time before their sexual debut."

Experts remain emphatic, however, that male circumcision must not be viewed as a complete prevention tool. "It is refreshing to see that research is being put to use, but we should take precautions to ensure that we constantly give information that male circumcision must work along with other HIV infection prevention strategies to be effective," said Kawango Agot, head of the Nyanza Reproductive Health Society.

"We have plans to launch a study to look into the sexual behaviours of men who have been circumcised to find out if they are engaging in risky behaviours due to the fact that they have been circumcised," she added. "We hope this will ascertain if indeed people are engaging in [risky sex]."

A 2007 study http://www.plosone.org/article/info:doi%2F10.1371%2Fjournal.pone.0002443 in Kisumu, provincial capital of Nyanza, found that circumcision did not result in increased HIV risky behaviour. It found that as male circumcision became more widely promoted, there would be a need to monitor “risk compensation” associated with the procedure.

ko/kr/mw http://www.irinnews.org/report.aspx?ReportId=87074KAMPALA Tuesday, November 17, 2009 (IRIN) - Africa will fail to achieve most UN Millennium Development Goals unless countries adopt effective family planning programmes and control rapid population growth, experts warn.KAMPALA Tuesday, November 17, 2009 (IRIN) - Africa will fail to achieve most UN Millennium Development Goals unless countries adopt effective family planning programmes and control rapid population growth, experts warn.

"Africa has not done well in areas of family planning," Khama Rogo, World Bank senior adviser, said. "It is not that we cannot do well; we have not committed ourselves... family planning and population growth have a cross-cutting impact."

Rogo was speaking at a three-day international conference on family planning, organized by the Gates Foundation and Johns Hopkins and Makerere universities that began on 16 November in the Ugandan capital, Kampala.

More than 1,000 policy-makers, researchers, academics and health professionals from 59 countries are attending. Various speakers warned that the rate of Africa's population increase was too rapid, with women in some countries having on average seven children each.

"Family planning improves maternal health, thereby increasing women's productivity and reducing dependency at both family and national levels," Chisale Mhango, director of reproductive health at Malawi's Health Ministry, told IRIN.

"Fewer children means manageable education targets; more children means that parents will mainly educate sons, which promotes gender inequality," he added. "The fewer the children the better the care, the more the food, the lower the child mortality and there will be savings for health provision."

Malawi’s population is projected to reach 41 million by 2040 from 13 million currently. Child spacing, Mhango said, would reduce the economic burden on poor Malawian families, allowing them to invest more in each child’s care and education. This would improve family nutrition, education levels and living standards.

Education crucial

Worldwide, 200 million women seek to prevent unplanned pregnancies but cannot access contraception. This demand is estimated by the UN to grow by 40 percent by 2050 as young people enter prime reproductive ages.

Michael J. Klag, dean of the school of public health at Johns Hopkins, called for community education to ensure successful family planning policies.

"Populations need to grow and economies grow, but this must be done in such a way that ensures the health of our children," he said.

According to the World Bank, demographic health service surveys in Africa show that family planning needs have not been met by up to 30 percent, and by up to 41 percent in countries like Uganda.

"People want the services, but they cannot access them," Rogo told the meeting. "Statistics indicate that we have more people to feed, but few hands to work. We have a very big dependent population in Africa [because] 60 percent of the population is under the age of 15."

Some specialists at the conference called for more focus in global debates on the impact of population on climate change.

"If we are going to destroy our forests to create more homes and more farming areas, what will be the impact on the climate?" asked Jason Bremner, programme director in charge of population, health, environment at the Population Reference Bureau.

"There is a relationship between population growth and carbon emission which is as a result of human consumption," he added.

Humanitarian risk

The conference also seeks to lobby policy-makers to increase funding for family planning. This, participants said, would reduce global humanitarian risks.

"With higher population growth, there would be less land per holder and existing holdings would be divided among more family members," said Clive Mutunga, research associate with Population Action International.

"Smaller farms are less productive overall than larger holdings, which will lead to perennial food insecurity as land productivity reduces due to over-exploitation," Mutunga added.

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http://www.irinnews.org/report.aspx?ReportId=87081ISIOLO Tuesday, November 17, 2009 (IRIN) - Hundreds of people have fled their homes in Isiolo, eastern Kenya, following an attack by armed men that left 11 people dead in Kisima locality, the Kenya Red Cross Society (KRCS) said.ISIOLO Tuesday, November 17, 2009 (IRIN) - Hundreds of people have fled their homes in Isiolo, eastern Kenya, following an attack by armed men that left 11 people dead in Kisima locality, the Kenya Red Cross Society (KRCS) said.

"More than 100 Turkana [families] have left their homes since [15 November]," Gitonga Mugambi, the KRCS coordinator in Isiolo, said. "They are moving to the Ngaremara area [about 30km from Isiolo town], which they believe is safe."

Affected communities include the Turkana, who are said to have been behind the attack, the Somali, Borana and Samburu communities. One of those affected, Peter Kalapata, said: "Our women are unable to go to Isiolo town to sell charcoal or buy food; the sick cannot go to the hospital. Things are bad; we need security for all the communities."

The Kisima attack, which occurred about 5km from Isiolo town, also left six people injured, with hundreds of heads of livestock, which were later recovered, stolen, according to the Isiolo divisional police commander, Sammy Kosgey. Tension in Isiolo is still high and has affected learning, Kenya National Union of Teachers Isiolo Secretary, Mohamud Halake, told IRIN on 16 November.

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http://www.irinnews.org/report.aspx?ReportId=87082KAMPALA Monday, November 16, 2009 (IRIN) - The Uganda AIDS Commission (UAC) is revamping its national HIV information campaign after HIV prevention messages were less successful than hoped. KAMPALA Monday, November 16, 2009 (IRIN) - The Uganda AIDS Commission (UAC) is revamping its national HIV information campaign after HIV prevention messages were less successful than hoped.

"We shall use basic facts in the messages to communicate effectively because we have realized that the level of knowledge about basic facts on HIV information is quite limited," said Saul Onyango, senior health educationist with the UAC.

The term high-risk sex - previously defined as sex with an irregular partner - is to be redefined as sex with anyone whose HIV status is not known. As such, the term “most at-risk populations” will no longer refer to specific groups such as sex workers, fishing communities and men who have sex with men, but to all members of the population engaging in risky sex.

Campaigns aimed at ending cross-generational sex will be abandoned in favour of generic warnings about engaging in risky sex because of fears that young people may believe that sex within their own generation is risk-free. Officials have also said factors such as alcohol abuse, which predispose people to risky sexual behaviour, must be tackled alongside HIV prevention.

The commission has assembled a team of medical and communication experts to develop the new messages, and will work with English and local language media to disseminate them.

"We have to change the destiny of this country, even if it means putting back the drums of the 1980s that used to frighten people," said UAC director-general, David Kihumuro Apuuli.

An ominous drumbeat, followed by a booming voice warning that "AIDS kills", was the centre of a radio HIV prevention campaign when Uganda first began its fight against HIV in the late 1980s. Several senior officials - including Jesse Kagimba, senior presidential adviser on HIV/AIDS - have called for the return of fear-driven campaigns, which they say were instrumental in Uganda's initial success in lowering prevalence.

However, detractors of this method say the key to success in prevention is education, not fear. Some studies http://www.popline.org/docs/1323/147687.html show that scare tactics alone do not lead to behaviour change, but rather encourage denialism and fatalism. Experts also say that such campaigns promote stigma and discrimination, and that in the age of widely available life-prolonging antiretroviral medication, they could prove ineffective.

After successfully bringing prevalence down from more than 20 percent in the 1980s to about 6 percent by 2000, Uganda's HIV levels have stagnated, showing a marginal increase in prevalence over the past few years.

Tailored response

The new messages will attempt to bring the HIV response in line with the drivers of the epidemic. According to a recent study [http://www.unaidsrstesa.org/files/u1/Uganda_MoT_Country_Synthesis_Report_7April09_0.pdf], 37 percent of new Ugandan HIV infections are attributable to multiple partnerships, 35 percent occur within discordant monogamous couples, 18 percent are due to mother-to-child transmission, and 9 percent occur through commercial sex networks.

"We need to change the mentality and behaviour of men; they have multiple sexual partnerships now called side dishes, which is creating a web," Kihumuro said. "Before we know it the whole of Kampala [the capital] will be entangled into one web."

According to the UAC, there are 110,000 new HIV infections annually and 63,000 deaths from HIV-related illnesses.

The study found that although Uganda had made good progress in rolling out key HIV prevention services, the campaigns had not reached all sections of the population.

"Over three-quarters of all adults, including many people living with HIV, do not know their HIV sero-status; services for PMTCT currently reach less than half of pregnant women," it found. "Although condom use has increased, its coverage has not yet reached the critical levels necessary for it to impact on population level HIV transmission."

Kihumuro noted that there was an urgent need for the government to commit more resources to the fight against HIV/AIDS. At present, the government funds about 6 percent of the national HIV response.

"A lot of the money coming in is from donors; we cannot sustain this," he added.

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http://www.irinnews.org/report.aspx?ReportId=87053POCHALLA Monday, November 16, 2009 (IRIN) - An increasing number of people in Southern Sudan cannot find enough to eat or adequate pasture and water for their livestock, raising fears of conflict between communities over grazing lands, local leaders warned.POCHALLA Monday, November 16, 2009 (IRIN) - An increasing number of people in Southern Sudan cannot find enough to eat or adequate pasture and water for their livestock, raising fears of conflict between communities over grazing lands, local leaders warned.

"Where there was peace, there was no rain and then where there were good rains, there was insecurity," Kuol Manyang, governor of Jonglei State, said.

His counterpart from Upper Nile State, Gutlauk Deng Garang, warned that hunger would force pastoralist cattle herders to move their animals, sharply increasing the likelihood of clashes with rival ethnic groups.

"We expect the cattle herders to start moving soon, and then it is expected [that there will] be conflict between the Lou and the Jikany Nuer," Garang told IRIN recently. Conflict between the Shilluk and Dinka communities had added to food insecurity, he said.

More than 2,000 people have died and about 350,000 have been displaced by violence across Southern Sudan since January, according to the UN Office for the Coordination of Humanitarian Affairs.

The World Food Programme (WFP), which began airdropping food in the area on 4 November, estimates that 1.2 million people are already facing serious food insecurity in Southern Sudan.

"Air drops are a last resort to get food into these inaccessible places during this time of hunger," Michelle Iseminger, head of WFP in Southern Sudan, told reporters at Pochalla, a remote settlement on Sudan’s border with Ethiopia.

Wider problem

According to the UN Food and Agriculture Organization, the food insecurity in the region is part of the wider threat facing eastern Africa and the Horn, where prolonged drought and mounting conflict have left an estimated 20 million people needing food aid.

The warning came at a tense time for Southern Sudan, which is struggling to recover from a 22-year civil war that ended less than five years ago. Elections are due in April, followed by a referendum on the south's potential full independence in 2011.

"If we are not able to handle the situation well... repairing adequate supplies... we can expect very, very significant levels [of hunger] which can border on the red flag emergency, which becomes a famine," Hilde Johnson, the UN Children’s Fund (UNICEF) deputy executive director, said during an 8 November visit to Jonglei's capital, Bor.

"When natural resources are being diminished on a daily basis, you will see hard pressure coming in on already meagre resources," Johnson added. "This will exacerbate conflict, there is absolutely no doubt."

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http://www.irinnews.org/report.aspx?ReportId=87057GARISSA Monday, November 16, 2009 (IRIN) - Armed with a university certificate, Hubbie Hussein Al-Haji returned to her pastoralist community in Garissa, northeastern Kenya, expecting to serve as a veterinary health assistant. But she was refused the job.GARISSA Monday, November 16, 2009 (IRIN) - Armed with a university certificate, Hubbie Hussein Al-Haji returned to her pastoralist community in Garissa, northeastern Kenya, expecting to serve as a veterinary health assistant.

But she was refused the job. "When I came back to Garissa [Northeastern Province capital], I was told you [a woman] cannot treat our animals because you menstruate - it will make our cows perish," she told IRIN.

Al-Haji and a colleague then started a local NGO, WOMANKIND Kenya (WOKIKE) to provide leadership training to women. They also set up a sanctuary for girls at risk of female genital mutilation/cutting (FGM/C).

"Girls are often seen as an object for the pleasure of men," Al-Haji said. In her community, FGM is a highly valued ritual, marking the transition from childhood to womanhood.

At present, the centre is supporting 120 girls aged around six years old because they are at risk of FGM/C from age eight. The girls, most of whom have escaped FGM/C, are enrolled on the recommendation of the government children's department and the community.

"When we started the campaign against FGM, the community turned against us; it was a taboo subject," Al-Haji explained. "The most difficult men to work with were the educated ones who see you [an educated woman] as a challenge."

With time, WOKIKE received the support of local religious leaders, most of whom are Muslim. "[Now] the religious leaders are telling the community that FGM is not a religious obligation," she said.

One success story has strengthened Al-Haji’s resolve to support disadvantaged women in northeastern Kenya. Hafsa, who has been supported by the centre for 14 years, is about to join the University of Nairobi to study pharmacy.

"I was rescued from traditional practices like FGM and early marriage," Hafsa told IRIN, adding that she came to the centre from Ijara [a district south of Garissa] at four.

"You are discriminated against either way by the community if you have not been circumcised and by friends in schools outside northeastern if you have been circumcised," Hafsa, who went to a high school in eastern Kenya, said.

At least 32 percent of Kenyan women have undergone FGM/C, according to a report by the Population Council. Among communities such as the Somali, Abagusii, Kuria, Maasai and Samburu, more than 90 percent of women undergo it.

Women’s work

The situation of girls and women in neighbouring Wajir is no better, said Haretha Bulle, a programme manager with the Wajir South Development Association (WASDA).

"In a typical Somali household, the woman's labour is needed for cooking, taking care of small babies, and it is for this [reason] that girls are often pulled out of school," Bulle told IRIN.

A lack of awareness of the value of education and no boarding-school facilities for girls has had adverse effects.

"There is no man who will trust his daughter to go to school [alone] in town without her mother," she noted. "Yet for you to go to high school you have to go to primary [school]."

Many of the girls suffer FGM/C and cannot report the practitioners. "In April, a girl who underwent FGM bled to death. The circumciser was arrested, and then released," she said.

"They are often very old women who sometimes cannot even see," Bulle added. "FGM/C cannot go away overnight. You cannot tell the Somali not to circumcise - though they don't like the Pharaonic type."

The Pharaonic form of FGM, also known as infibulation, involves the total removal of all external sex organs before the vagina is sewn up, leaving a small opening for the passing of menstrual blood.

At home, the girls too are exposed to gender-based violence, but the communities do not see it as a problem, Bulle added.

"If you try to intervene, you end up being accused by the woman herself of interfering," she explained. "[However], I cannot say that the [reported] cases of rape here are alarming."

The bigger problem was lack of support systems. "Care services for abused women in this part of the country are almost non-existent," she said. For instance, if a woman has been raped, "PEP [post-exposure prophylaxis] ... [is] only in the books in this part of the world". PEP services within 72 hours of HIV exposure help to prevent infection.

High divorce rates

In the town of Moyale, along the border with Ethiopia, women and girls were seen as "inferior" to men, assistant chief for Odda location, Rashid Osman, said.

"A woman can get married but at the end when there is a divorce, she does not get her rights," he said. "Here, people seem to marry and divorce anyhow. Consequently, there are many divorcees and neglected children."

Despite awareness-raising, traditional perceptions are hard to change. "You hear men saying that by the end of the next rains, I must marry a fourth wife then I will go for Hajj. You would expect Hajj to be more of a priority," he said.

"Sometimes people marry for very strange reasons... like to take care of the cows since the town is growing and herders have to go further out to the fields."

Across northeastern Kenya, said Rashid Karayu, chairman of the Global Integrated Development Programme, a local NGO, women were more disempowered than in other areas.

"The perception from the people and even the women themselves is that they are inferior," he told IRIN. "Even in school committees, women who are best placed to speak for their children often shy away."

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http://www.irinnews.org/report.aspx?ReportId=87063WAJIR Friday, November 13, 2009 (IRIN) - Khadijah Ibrahim is a mother of six in the northeastern Kenyan district of Wajir East. The area has suffered recurrent droughts and is now facing the risk of flooding from El-Nino rains. For now, however, the effects of the drought continue to be felt, as Khadijah told IRIN: WAJIR Friday, November 13, 2009 (IRIN) - Khadijah Ibrahim is a mother of six in the northeastern Kenyan district of Wajir East. The area has suffered recurrent droughts and is now facing the risk of flooding from El-Nino rains. For now, however, the effects of the drought continue to be felt, as Khadijah told IRIN:

"My husband, who is a nomadic pastoralist, moved away with the livestock when the drought became very serious and some of the animals started dying, but we are hopeful that he will return now that the rains have started.

"When he left, my children and I were left behind as usual. We could not go with him as the children were already enrolled in school here.

"Sometimes my husband is gone for long but he always sends back some money from the grazing fields for the upkeep of the family. He sends the money with the drivers along the highway.

"But the money has been reducing as some of the livestock died along the way. Now my husband has been sending me less money yet the prices of food have gone up because of the drought.

"The children are not able to get milk since all the cows have moved away. With the drought, the price of milk from goats, cows and camels has all gone up. We are now buying a litre of goat’s milk at 120 shillings [US$1.6]. Camel milk, which used to be the cheapest, is now selling at about 70 shillings [90 US cents].

"But we are expecting the price of milk to go down, as with the rains, the animals will return.

"The price of food is still high with a kilogram of maize flour now selling at 80 shillings [$1.06] - up from 60 [80 US cents] in September. The price of meat, milk and vegetables has also gone up.

"Getting food is hard for most families here in Wajir but I would say that I am a little luckier as I live closer to the town [Wajir]."

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http://www.irinnews.org/report.aspx?ReportId=87025JUBA Friday, November 13, 2009 (IRIN) - Reported cases of kala azar infection, a deadly disease also known as visceral leishmaniasis, have continued to rise in Southern Sudan, according to medical workers.JUBA Friday, November 13, 2009 (IRIN) - Reported cases of kala azar infection, a deadly disease also known as visceral leishmaniasis, have continued to rise in Southern Sudan, according to medical workers.

"We are clearly in the midst of a kala azar epidemic," Jill Seaman, working in the Old Fangak clinic in Jonglei State, run by the Sudan Medical Relief organization, said.

"Our numbers are remaining high - with 80 admissions in the past week and patients coming daily," Seaman, an infectious disease expert, said in a 12 November email to IRIN.

The outbreak, which is transmitted by the sand fly, has hit some of the most remote and difficult-to-access regions of Upper Nile and Jonglei states, areas also suffering from recent inter-ethnic clashes.

The disease is almost always fatal within one to four months unless treatment is given, but some 95 percent recover if treated in time.

However, many patients were arriving too late at health centres, Seaman said. "Some people come to die the same day," Seaman said. "There is so much anaemic heart failure in the early months of an outbreak, requiring blood transfusion - if at all possible."

MSF teams

Médecins Sans Frontières (MSF - Doctors Without Borders) has sent emergency teams into Upper Nile and Jonglei to try to treat those they can reach.

"Numbers continue to increase in terms of admissions and those being treated, but the main concern is that there are many still in remote areas who are not receiving treatment," said Ross Duffy, who heads MSF Holland in Southern Sudan.

The disease suppresses the immune system, leaving victims open to other infections such as malaria or pneumonia. Symptoms include fever, diarrhoea, vomiting, nosebleeds, a swollen spleen and jaundice.

"The symptoms can appear like malaria, and there is not a huge awareness of kala azar in many communities, but we are working to get the message out," Duffy added.

With poor or badly timed rains meaning failed harvests, coupled with months of insecurity caused by inter-ethnic clashes, many people are already weakened.

"Other NGOs are now looking for spots not well covered - there are surely people dying in their villages without coming for care," Seaman added.

Many of those received by clinics are children, according to the World Health Organization (WHO), which is supporting efforts to treat those affected.

"Children account for a significant proportion of the outbreak: admission figures over the past two months show that 42 percent of patients were children under five, and 47 percent aged 5-17," a 9 November WHO health situation report said.

Kala azar is endemic in some parts of Southern Sudan and outbreaks occur every 5-10 years. Treatment involves an injection every day for a month - requiring patients to stay near health facilities, which can put enormous pressure on those caring for them.

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http://www.irinnews.org/report.aspx?ReportId=87027KAUDA Thursday, November 12, 2009 (IRIN) - The Nuba Mountains, a former frontline region in Sudan’s north-south civil war remain tense, years after the 2005 north-south peace agreement, local leaders and analysts say.KAUDA Thursday, November 12, 2009 (IRIN) - The Nuba Mountains, a former frontline region in Sudan’s north-south civil war remain tense, years after the 2005 north-south peace agreement, local leaders and analysts say.

Comprising some 48,000sqkm of green uplands and farmland, the area is part of northern Sudan’s Southern Kordofan State, but as during the war, remains politically dominated by the southern-led Sudan People’s Liberation Movement (SPLM).

Tensions and mistrust have remained high between Sudan’s north and south - major political, ideological and religious differences are unresolved – not least in the Nuba region.

"Security is a big problem, with violations and hostility between two parties - the SPLM and the NCP [National Congress Party], and a lot of conflict between tribes," said Kamal al-Nur, commissioner of SPLM-controlled Heiban County in Southern Kordofan.

"We are concerned that violence will escalate as we come closer to the elections - and in the period after the elections - to the referendum," al-Nur added. General elections in Sudan are slated for April 2010, before a southern independence referendum in 2011.

During the war, the Nuba population suffered aerial bombardment, isolation, shortages, land expropriation and forced population movements, according to international human rights groups.

The area is characterized by a mix of ethnic groups and coexistence between Muslim, Christian and traditional believers.

"We fought for long years… for equality, for the right to live as we want and not under the [Islamic] Sharia law of the north," said Younan Albaround, the SPLM chairman in Kauda, the party’s former headquarters for Nuba during the war.

“Popular consultation”

Unlike Southern Sudan and the oil-rich region of Abyei which are due to vote on independence and self-determination in 2011, the 2005 peace deal only set out arrangements for interim power sharing and ”popular consultation” in Southern Kordofan and Blue Nile states.

Abyei, Nuba Mountains and Blue Nile are sometimes referred to as Sudan’s “three areas” – transitional and contested-zones straddling the north-south political, military and cultural fault lines.

"Whilst the South and Abyei have clearly defined rights to an independence referendum - guaranteed by the presence of the SPLA and thus with the option of unilateral secession should the peace deal fail to be fully implemented - the two `contested areas’ are only given the ill-defined concept of `popular consultation’ on their future status," said Peter Moszynski, a Sudan analyst who began working in the Nuba region in 1981.

The SPLA’s ranks in the Nuba mountains were largely filled by local people, but those forces have officially pulled out of the region under terms set down by the peace agreement, with only special joint north-south units remaining.

Tensions have also risen following recent comments by senior Southern Sudanese officials in favour of separation, including a speech by the Southern president, Salva Kiir, that voting for unity would make southerners "second class" citizens.

"The Nuba people fear the breakaway of the south because they will be left as an isolated minority in the north - and will also be on the frontline of any future north-south conflict," Moszynski said.

"There are huge concerns that the Nuba Mountains could return to fighting," said Sudan analyst, John Ashworth. "They have no referendums - but many ordinary people are not aware of that yet and will be angry when it finally dawns on them. The `popular consultation’ is vague and probably meaningless."

A public opinion study by the Washington-based National Democratic Institute (NDI) found people saw few positive outcomes for the future.

"Participants report that there is persistent, and potentially explosive, conflict in Southern Kordofan," the March 2009 study entitled Losing Hope noted.

In ethnic terms, the people of the Nuba Mountains usually identify more closely with the “African” southerners than their northern Arab neighbours.

"They describe the conflict as a fight over land and grazing rights. The Nuba argue that Arabs are armed [while the Nuba are not], that Arab traditional leaders are not neutral, and that the central government is behind much of the violence," it added.

"Arab participants say that it is the Nuba who are the instigators, and that they are responsible for the violence and theft in the region."

Few, the study found, were optimistic for the future: "The scale of the current conflict in Southern Kordofan is such that many participants believe the state is close to a return to general, state-wide war."

Similar sentiments were echoed by the International Crisis Group (ICG) in October 2008, in a report on Southern Kordofan entitled The Next Darfur?

"If the NCP, SPLM and international community fail to pay the required attention to the divided region," the ICG warned, "their inaction could come back to haunt them in a way that threatens the stability of the already divided country."

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http://www.irinnews.org/report.aspx?ReportId=86994LAMU Thursday, November 12, 2009 (IRIN) - Eight people have died on the Kenyan district of Lamu and others have been hospitalized following a suspected outbreak of acute watery diarrhoea (AWD), an official said.LAMU Thursday, November 12, 2009 (IRIN) - Eight people have died on the Kenyan district of Lamu and others have been hospitalized following a suspected outbreak of acute watery diarrhoea (AWD), an official said.

The spread of AWD could be attributed to recent floods in the area which have seen people displaced, said Lamu District Medical Officer Mitwani Bijuma.

The most affected areas were Langoni, Mkomani, Kandahar and Kijitoni.

Lamu principal chief Jamal Mzee Fangupi told IRIN street food vendors and social gatherings had been banned, and hygiene awareness programmes were in place, to curb the spread of the disease.

Recent floods have left thousands homeless in Lamu and the neighbouring districts of Malindi and Magarini.

jk/aw/cbhttp://www.irinnews.org/report.aspx?ReportId=87001DUSHANBE Thursday, November 12, 2009 (IRIN) - Even as world food production grows, hunger is on the rise in many poor countries, according to the Global Crop Prospects and Food Situation report for November, published by the Food and Agriculture Organization (FAO) on 12 November.DUSHANBE Thursday, November 12, 2009 (IRIN) - Even as world food production grows, hunger is on the rise in many poor countries, according to the Global Crop Prospects and Food Situation report for November [http://www.fao.org/docrep/012/ak340e/ak340e00.htm], published by the Food and Agriculture Organization (FAO) on 12 November.

The report highlights a contradiction: world cereal production is at its second-highest level ever, yet food prices remain very high. It identifies 77 countries that are both low-income and food deficit.

In East Africa, cereal prices range from 68 percent to 177 percent over the 2007 numbers. In southern Africa, prices are 58-200 percent higher than in 2007, and in most of Asia prices are up 40-70 percent. Since most low-income food deficit countries are food importers, they lose far more from high prices than they gain from steady crop production.

Hunger, in most cases, is caused by lack of money rather than a shortage of food production, according to the World Food Programme (WFP). [http://www.wfp.org/hunger/causes] In 2008 the number of undernourished people in the world increased by 40 million, despite record harvests. [http://www.fao.org/news/story/en/item/8836/icode/]

The new FAO report suggests that 2009 is likely to see a similar increase in hunger.

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http://www.irinnews.org/report.aspx?ReportId=87006JOHANNESBURG Wednesday, November 11, 2009 (IRIN) - A move by donor countries to provide aid agencies with cash, allowing them the flexibility to source cheaper or more appropriate food in the region or beneficiary country and save on transport and warehousing costs, is not addressing nutritional needs, according to a new report.JOHANNESBURG Wednesday, November 11, 2009 (IRIN) - A move by donor countries to provide aid agencies with cash, allowing them the flexibility to source cheaper or more appropriate food in the region or beneficiary country and save on transport and warehousing costs, is also not addressing nutritional needs, according to a new report.

Food aid should include foodstuffs fortified with micronutrients and animal protein. "The emphasis is more on quantity rather than quality, and rarely does the food aid target the most vulnerable groups: children under five, pregnant women and lactating mothers," said Stéphane Doyon, of the international medical charity, Médecins Sans Frontières (MSF), a co-author of the organization's report, Malnutrition: how much is being spent?

"Barely 1.7 percent of interventions reported as 'development food aid/food security' and 'emergency food aid' between 2004 and 2007 actually address nutrition needs," he said.

The MSF report was published ahead of a new UN Children's Fund (UNICEF) report, which points out that the level of child and maternal undernutrition "remains unacceptable" throughout the world; 90 percent of the developing world's chronically undernourished or stunted children live in Asia and Africa.

jk/he http://www.irinnews.org/report.aspx?ReportId=86993NAIROBI Tuesday, November 10, 2009 (IRIN) - Three years after the Kenyan government began to promote emergency contraception as part of its family planning strategy, the “morning-after pill” remains as controversial as ever: critics argue that unless the public is better educated about its purpose, it risks undermining the messages of abstinence and protected sex, putting impressionable young people at risk of HIV.NAIROBI Tuesday, November 10, 2009 (IRIN) - Three years after the Kenyan government began to promote emergency contraception [http://www.who.int/mediacentre/factsheets/fs244/en] as part of its family planning strategy, the “morning-after pill” remains as controversial as ever: critics argue that unless the public is better educated about its purpose, it risks undermining the messages of abstinence and protected sex, putting impressionable young people at risk of HIV.

"When you speak to young girls and the youth, they confide that unwanted pregnancy rings more in their minds than the possibility of contracting venereal diseases or HIV," said Anne Muisyo, coordinator of the Abstinence and Worth the Wait programme at Crisis Pregnancy Ministries. "It is the very reason I have qualms about a campaign telling people to relax because there is a pill they can run to after engaging in unprotected sex."

Muisyo's fears seemed borne out by students IRIN/PlusNews spoke to in the Kenyan capital, Nairobi. Jack*, a student at the Kenya Polytechnic University, says even though he fears HIV, he finds some reassurance in the existence of the pill.

"You know for us young people, we engage in quick and unplanned sex, for example at a party... You get a girl and you do not have a condom, what do you do? Let the opportunity pass by? No," he said. "Do it and give her some small money for a pill tomorrow."

Molly*, a student at the same university, said: "It's not that I do not use condoms at all with my partner, but the comfort you get when you realize there is a pill which is available cheaply is very tempting."

"You give yourself the belief that just once will not bring damage," she added.

The government is keen to stress that emergency contraception must not replace the condom.

Not a replacement for condoms

"I think it is important to note that we have been very consistent in our condom use promotion campaigns and we are not ready to change course because it prevents both pregnancies and HIV," said Shahnaaz Sharif, the director of public health at the Ministry of Public Health. "We have also been very consistent in saying that these pills do not in any way prevent one from contracting HIV."

Experts warn that unless the messages about emergency contraception are accompanied by further education on family planning and warnings about the dangers of unprotected sex, the government's campaign could backfire.

A study published in a recent edition of the East African Medical Journal found that just 15.8 percent of sexually active students said they used condoms every time they had sex, compared to 22.5 percent who reported never having used a condom.
Need for more education

"Various studies have shown that the sexual debut amongst the youth is happening very early," said Marsden Solomon, regional medical adviser for reproductive health NGO Family Health International. "Because a pregnancy has an immediate effect on them both psychosocially and economically, they would jump into anything that presents an opportunity to prevent it, and an emergency pill provides that opportunity for them."

"What they forget is that while they might have prevented an unwanted pregnancy, they have not done anything to protect themselves from HIV and any other sexually transmitted disease," he added. "I think the message to the youth should be abstinence, and for those who cannot, then dual protection methods like other long-term contraceptives together with a condom should be the most appropriate."

Solomon noted, however, that the emergency pill should not be dismissed altogether, noting that with proper education, it could form a useful tool in a much-needed national family planning push. According to the 2003 Kenya Demographic and Health Survey (KDHS), nearly 20 percent of births in Kenya are unwanted and a further 25 percent happen at an unwanted time.

A study by social marketing group Population Services International - the government's partner in the national emergency contraception campaign - reported that the average age of women who use emergency pills regularly is 24.

(* not their real names)

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http://www.irinnews.org/report.aspx?ReportId=86953MASINDI Tuesday, November 10, 2009 (IRIN) - Forced repatriation of displaced persons in Uganda to their original homes in the north is "inhuman and against the government policy of voluntary return", local officials have said.MASINDI Tuesday, November 10, 2009 (IRIN) - Forced repatriation of displaced persons in Uganda to their original homes in the north is "inhuman and against the government policy of voluntary return", local officials have said.

Hundreds of internally displaced persons (IDPs) who fled clashes between the rebel Lord's Resistance Army (LRA) and government forces in the 1990s, and sought refuge in the central district of Masindi, were recently rounded up by local authorities and sent back on trucks to northern districts.

"We hear that these IDPs are being rounded [up] and loaded into trucks and brought back to their districts in northern Uganda; this is against the principle of the voluntary return of formerly displaced persons to their homes," Kitgum District [northern Uganda] chairman John Ogwok Komakech said.

Sources in Masindi said 2,492 IDPs living in Kihura A village, 1,300 in Kihura B, 1,511 in Kasubi and 1,843 in Nyamiringa were to be repatriated.

The Disaster Preparedness and Recovery Coordinator for the Office of the Prime Minister in Amuru, northern Uganda, Lilly Adong, said the government had intervened.

"The whole exercise was stopped because it was done in total violation of IDP rights… IDPs being repatriated have expressed concern over their security and dignity," she told IRIN. "These people were loaded into a truck and dumped in Amuru at a police station without our notice."

Joseph Otto, who fled Mucwini village in Kitgum District in 1996, said he would remain in Kitgum town because he could not go back to the village with nothing to start a life.

Other IDPs said they were born in Masindi and did not know where to go, while some had vegetable gardens or children at school in Masindi.

"I was forced onto the truck by one of the law enforcement officers in Nyamiringa village where I was living," Harriet Achayo, who fled Guru-Guru village in Amuru District in 1997, told IRIN at Ociti return site in Amuru. "They said they were taking us back because the land we are occupying will be planted with sugar cane."

Achayo and 122 other IDPs were dumped at Amuru police station, local officials said. Another 93 were taken to Pader District.

Relative peace returned to northern Uganda after the signing of a cessation of hostilities agreement between the LRA and the government in 2006. Since then, most IDPs have returned to their original villages.

Observers, however, say services at places of return are failing to meet the demands of returning populations. These include schools which lack housing for teachers, classrooms, latrines and water points.

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http://www.irinnews.org/report.aspx?ReportId=86958NAIROBI Tuesday, November 10, 2009 (IRIN) - Armed groups in Sudan's Darfur region have continued to violate a UN arms embargo as well as international humanitarian and human rights law, a new report by a UN panel of experts has said.NAIROBI Tuesday, November 10, 2009 (IRIN) - Armed groups in Sudan's Darfur region have continued to violate a UN arms embargo as well as international humanitarian and human rights law, a new report by a UN panel of experts has said.

"All parties to the conflict continue to fail to meet their affirmative obligations under international humanitarian and human rights law in areas under their control," the report said.

"Among the armed movements, the Justice and Equality Movement (JEM) is the most active violator of the arms embargo, carrying out repeated attacks," it said.

Sudan has rejected the report saying it would demand that the Security Council terminate the panel’s mandate. "We are fed up with this committee," news reports quoted its ambassador to the UN, Abdel-Mahmoud Abdel-Halim, as saying. "Our position is a total rejection of this report."

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http://www.irinnews.org/report.aspx?ReportId=86960LESIDAI Tuesday, November 10, 2009 (IRIN) - Many Kenyan children are in school, but enrolment in the north has been adversely affected by insecurity, food scarcity and traditional attitudes, residents and teachers said.LESIDAI Tuesday, November 10, 2009 (IRIN) - Many Kenyan children are in school, but enrolment in the north has been adversely affected by insecurity, food scarcity and traditional attitudes, residents and teachers said.

"I just joined a new school a few weeks ago [20 October]," 14-year-old Kelly Lanyasunya said at Lesidai primary school in Samburu Central District (central-northwestern Kenya). "I got a new uniform and I am making friends but if this area gets insecure, I will have to move to another school."

Like her classmate, Nabik Kekichorumongi, is forced to change schools whenever bandits attack the surrounding villages.

Stephen Leparachwo, head teacher at Lolkunono primary school in Samburu Central, said Lesidai primary school often receives parents bringing their children from Pura, a neighbouring area affected by banditry.

"When they come, some are even without food… The bandits follow the fleeing residents [and their cattle], not giving the children a chance to read," he said.

Cattle-rustling

Much of the insecurity is due to cattle-rustling between the Samburu, Pokot, Turkana and Borana communities, according to local residents. In September, for example, Pokot cattle raiders killed 32 people in Samburu Central.

Rustling has also affected food production, especially in fertile areas like Ngano on the Kirisia ranges, where bandits lurk in the beautiful landscape.

In 2008, insecurity worsened in Ngano, according to the headmaster of a local school, Simon Lenolkulal. "We could hear gunshots, so we were seeking cover on the ground with the children," he said, recalling a recent incident.

"There is a high rate of transition even of school teachers here… Teachers are reluctant to work here because of the insecurity. One week there is peace, the next week we are moving... Every week we enrol new children, then when there is tension they leave."

The school relies on food aid from agencies like the UN World Food Programme (WFP). According to Lenolkulal, however, people could farm the land and eliminate food aid, if there were more security.

At neighbouring Lgoss primary school, deputy head teacher Bernadeta Lesuruan told IRIN: "When there is conflict and the parents flee, we have more children coming to the classes."

Hunger

Food scarcity tends to drive up school attendance, local residents said.

When there is a general food distribution, enrolment in school goes down, while in more difficult times the number of children increases, Lesuruan said.

"During such times you see young children carrying toddlers to school for the food… During the drought, the children were entirely relying on food in school. Some were fainting after coming from home hungry. When there is no food [at all], school attendance is very low."

In August, WFP was feeding at least 900,000 children in schools to help drought-affected families in Kenya's arid and semi-arid regions.

"Food is an issue," said Peter Emanman, the school feeding programme officer in Samburu Central.

Recent rain has brought hope of an improved food situation. "People are starting to plant but the food crops will not be ready by December [the next school holiday month]. What will happen then?" Emanman asked.

Few girls at school

There are few school teachers and hardly any female teachers. At Lgoss, Lesuruan was the only female member of staff.

"Since I came here [in 2008] more girls are staying in school especially those who would run away for the period of their menstruation," said Lesuruan. "I bring pads to the school for the girls."

Apart from the location of the school, 12km from the nearest shopping centre, the high cost of sanitary pads also feeds absenteeism.

Early marriages also affect girls’ attendance at school: Most drop out in the middle primary school classes. In 2008, some Samburu schools had no girl candidate sitting the national primary school leaving exam.

"There is a mentality that if girls are educated and get jobs, the earnings will not return home but go to the husband," said another teacher.

Most of the boys in school are late entrants; some of the girls stay at home to work. "In this community people are not fond of keeping children in schools," the teacher added.

Night school

However, some communities are trying to educate residents about the value of education: Currently under way in Baragoi District, the pastoralist night school initiative targets cattle herder children who are unable to attend day school.

"The children leave the fields at 4pm and then attend class," said Emanman. "The students get `uji’ (maize meal porridge) in the evening and are taught until 10pm."

Some children from these schools have progressed to the formal education system, but the night school initiative is largely designed to teach basic literacy to herders and others, he added.

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http://www.irinnews.org/report.aspx?ReportId=86968NAIROBI Tuesday, November 10, 2009 (IRIN) - Kenyan officials are protesting as 'unfair' a recommendation by the technical review panel of the Global Fund to reject the country's bid for Round Nine funding.NAIROBI Tuesday, November 10, 2009 (IRIN) - Kenyan officials are protesting as 'unfair' a recommendation by the technical review panel (TRP) of the Global Fund http://www.theglobalfund.org to reject the country's bid for Round Nine funding.

James Ole Kiyapi, permanent secretary in the Ministry of Medical Services and chair of Kenya's country coordinating mechanism http://www.theglobalfund.org/en/ccm/?lang=en, who is responsible for submitting grant proposals to the Fund, said the main reason for the TRP's recommendation was that Kenya's two ministries of health had failed to properly coordinate the management of resources.

In 2008 Kenya split its health ministry into the Ministry of Public Health and Sanitation, and the Ministry of Medical Services. Local media have reported wrangling over roles and access to financing - at one point both ministries appointed someone as head of the National AIDS and Sexually Transmitted Infections Control Programme, a major HIV/AIDS body.

The final decision on the recommendations of the TRP lies with the Global Fund Board http://www.theglobalfund.org/en/board/?lang=en, which is meeting in Addis Ababa, Ethiopia.

A high-powered delegation has been sent to appeal the decision. "We hope our side of the story will be heard," said Ole Kiyapi. The country is requesting US$270 million from the Fund.

Kenya's 2008 proposals http://www.theglobalfund.org/en/fundingdecisions/notapproved for funding for HIV, TB and malaria were also rejected; in 2003 the Global Fund delayed the disbursement of funds over concerns about corruption in the National AIDS Control Council.

Analysts say a recent row http://www.plusnews.org/Report.aspx?ReportId=86496 among HIV/AIDS NGOs over funding could also have played a part in the TRP's decision.

"We as a country have done a shoddy job of managing previous funds. Let this be a wake-up call, and let us learn from our mistakes and tackle the problems that have put us here in the first place," said James Kamau, head of the Kenya Treatment Access Movement, a national advocacy group.

Aidspan, an independent watchdog of the Global Fund, http://www.aidspan.org/index.php?page=gfgrants&menu=globalfundgrants&country=96, gives Kenya a 'D' in terms of grant performance, noting that on average Kenya grants are almost nine months behind schedule.

"If the bid is rejected outright people will die, because the government itself contributes nothing to HIV treatment in this country," Kamau said, adding that the government should start funding its own HIV programmes rather than relying so heavily on donors in order to avoid such uncertainty in the future.

The Global Fund, Kenya's biggest HIV/AIDS donor, has contributed over US$87 million to prevention, treatment and care programmes; more than 200,000 Kenyans are receiving antiretroviral medication.

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http://www.irinnews.org/report.aspx?ReportId=86969NAIROBI Monday, November 09, 2009 (IRIN) - A planned national survey of men who have sex with men (MSM) will be the first step in the government's plan to incorporate this high-risk group into the country's HIV programme, a senior government official has said.NAIROBI Monday, November 09, 2009 (IRIN) - A planned national survey of men who have sex with men (MSM) will be the first step in the government's plan to incorporate this high-risk group into the country's HIV programme, a senior government official has said.

"We have continued to ignore this group of people yet they are responsible for a big chunk of new HIV infections; we have resolved as a government that we cannot sit back and wait for things to get out of hand," said Nicholas Muraguri, head of the National AIDS and Sexually transmitted infections Control Programme (NASCOP).

There have been few studies on HIV among MSM in Kenya; a survey of 285 men in Mombasa in 2007 found an HIV prevalence of 43 percent among men who had sex with men exclusively, compared with 12.3 percent among men who had sex with both men and women. Kenya's national HIV prevalence is 7.4 percent.

HIV programming for MSM is extremely limited despite the country's national strategic plan for HIV/AIDS classing them as a “most at-risk population”.

"We cannot do this [provide HIV programmes for MSM] without knowing roughly how many they are and what special needs they require; I hope the survey that we will embark on will help us answer some of these questions," Muraguri said.

He noted that the survey - due to start in December and last six months - will attempt to discover information such as the specific sexual health risks and needs of MSM, MSM “hot spots” around the country, and the number of MSM-friendly health facilities available.

It will use respondent-driven sampling, recruiting openly gay men to reach out to other MSM who may not be out of the closet, and using existing MSM-friendly facilities to help conduct the research.

High hopes for better services

Joshua* is a male commercial sex worker in Nairobi who recently received training from NASCOP on reaching out to his peers with HIV/AIDS messages.

"Today I talked to 75 male commercial sex workers - 40 of them are HIV-positive but they do not know what to do," he told IRIN/PlusNews. "Many are homeless after being kicked out of their homes due to stigma."

Joshua hopes the survey will enable the government and NGOs to provide more services to MSM.

"Currently at a clinic in Nairobi, we are given one bottle of [water-based] lubricant to last three months but you know as a commercial sex worker, you finish it in a week," he added. "So it means for the remaining time, you engage in sex without the lubricant, putting yourself at great risk."

He noted that there was also a lack of sufficient knowledge about the risks associated with HIV and anal sex in the general population. "Many women [clients] approach us for anal sex wrongly believing that it lowers their chances of getting infected," he said. "Everybody should be educated on the dangers of this kind of sex because it seems people have the wrong perception."

However, not all MSM are as enthusiastic about the prospect of being counted and questioned by a government that has thus far shown little support for the rights of MSM.

Not everyone on board

"People in this country are still very homophobic and we are stigmatized a lot; who will want to come out to agree that he is a homosexual? Let them address issues of stigma first," said Donald*, who has not come out of the closet. "How do you convince me to come out and say I am a homosexual yet the same government that is asking me to do this criminalizes what I am engaged in?"

"I would rather they offered the services without going into the business of knowing who we are and trying to count us," he added.

Proof that homosexuality remains taboo in Kenya was not hard to come by on the streets of Nairobi: "To say they want to offer services to people who are engaged in acts that do not conform to the law is taking this issue of human rights too far," said Lynette Moseti. "That money can be used to help children who are living with HIV."

Homosexuality remains illegal in Kenya, punishable by up to 14 years in prison. According to Muraguri, however, the urgency of the problem necessitated ignoring the law. "Rigidity will only make our situation worse," he said.

Muraguri stressed that the government's survey did not intend to stigmatize MSM.

"We appreciate the stigma these people face and that would be [the] last thing we would want to do; even in other mainstream HIV services that the government offers we use data to offer services, so I do not think there is anything unusual about the survey," he said.

Lorna Dias, MSM coordinator at Liverpool VCT (voluntary counselling and testing), Care and Treatment, one of the only organizations in the country that provides services to MSM, says the planned survey shows that the government is serious about tackling the epidemic among most at-risk populations.

"It is a positive step and a clear indication that the government is ready to open up to the reality that men who have sex with men pose a great risk to the war against HIV unless they are integrated within mainstream HIV and AIDS programmes," she said. "The next step should be to de-stigmatize them and see them as normal people who need services like everybody else."

*(not their real names)

ko/kr/cbhttp://www.irinnews.org/report.aspx?ReportId=86932MALAKAL Monday, November 09, 2009 (IRIN) - Hundreds of cases of kala azar (also known as visceral leishmaniasis), a parasitic disease transmitted by the sand fly, have been reported in Southern Sudan in the past month, aid workers and doctors have said. MALAKAL Monday, November 09, 2009 (IRIN) - Hundreds of cases of kala azar (also known as visceral leishmaniasis), a parasitic disease transmitted by the sand fly, have been reported in Southern Sudan in the past month, aid workers and doctors have said.

"The numbers have surprised us, but we are coping and are treating those we receive," said Tut Gony, director of Malakal hospital in Upper Nile State.

Kala azar is endemic in some parts of Southern Sudan and outbreaks occur every 5-10 years. The sudden rise in cases has caused concern, said Gony, because it has hit some of the most remote and difficult-to-access regions of Upper Nile and Jonglei states, areas also suffering from recent inter-ethnic clashes.

For treatment to be effective it needs to be prompt. Malakal hospital had recorded over 70 cases since 23 October, with numbers expected to rise further, hospital officials said.

"Those who reach the hospital here, have had a difficult journey usually by boat because there are few roads, and where there are roads many are closed due to the rains," Gony added.

Over the weekend, IRIN found many patients resting under the shade of trees in the Malakal hospital compound.

In a 6 November statement, the medical charity Médecins Sans Frontières (MSF) said it had treated 107 patients since October - compared to 110 in the whole of 2008.

An additional 275 were being treated by a Sudanese NGO, which it did not name, in Old Fangak, Jonglei State.

The disease is almost always fatal within one to four months unless treatment is given, but some 95 percent recover if treated in time, MSF said.

Challenge

Health workers in the underdeveloped south face huge challenges. Both Jonglei and Upper Nile have suffered a string of inter-ethnic clashes in recent months.

"In Southern Sudan, where almost three-quarters of the population have no access to even the most basic healthcare, it is a race against time to reach patients," said David Kidinda, MSF medical coordinator for Southern Sudan.

"We suspect that the number of kala azar patients reaching clinics in some areas is just the tip of the iceberg… Without treatment, those infected can die within weeks if their immune system is already weakened," he said.

Treatment involves an injection every day for a month - requiring patients to stay near health facilities, which can put enormous pressure on those caring for them.

"With all the barriers facing people here - the severe lack of infrastructure, few proper roads, the crippling absence of healthcare staff and structures, and the current increase in violence and insecurity - survival becomes a cruel obstacle course for those in need of life-saving treatment," Kidinda said.

The disease suppresses the immune system, leaving victims open to other infections such as malaria or pneumonia. Symptoms include fever, diarrhoea, vomiting, nosebleeds, a swollen spleen and jaundice.

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http://www.irinnews.org/report.aspx?ReportId=86940JUBA Thursday, November 05, 2009 (IRIN) - Sudan has started registering voters for presidential, legislative and regional elections, but officials in the south and international observers say the process has begun on a flawed note.JUBA Thursday, November 05, 2009 (IRIN) - Sudan has started registering voters for presidential, legislative and regional elections, but officials in the south and international observers say the process has begun on a flawed note.

"This process could easily be referred to as ‘dead on arrival’," Anne Itto, secretary-general for the south of the Sudan People's Liberation Movement (SPLM), said on 3 November.

The National Election Commission (NEC) deputy head Abdalla Ahmed, however, told the Sudan Tribune on 2 November that the NEC had mobilized concerned authorities to ensure the success of the exercise.

The month-long process began on 1 November. It is a key step towards the April 2010 polls that are seen as a landmark of the 2005 peace agreement that ended two decades of civil war between north and south.

An estimated two million people died in that war, which ended with the signing of the Comprehensive Peace Agreement (CPA).

"In the context of Southern Sudan, where you don’t have [telephone] networks, where you don’t have roads, where you don’t have public transport, it is very unrealistic to expect registration to be completed by 30 November," Itto told reporters in the Southern capital, Juba.

Should the NEC fail to take immediate and drastic action, warned the SPLM, fewer than 10 percent of eligible voters in the south would be able to register and vote.

"If things go the way they are going now, I believe less than 10 percent of the total population will be registered," Itto said.

The NEC has set up some 15,000 registration centres to cater for an estimated 20 million Sudanese voters.

Concerns

Observers, however, said the centres had been slow to open even in state capitals, and reports indicated that access for rural populations was poor.

Awareness that registration had begun or even knowledge of the need to register was low, while state election committees had complained of delays in operational funding.

Those concerns were echoed by the US-based Carter Center, whose international observers are monitoring the electoral process, which said more must be done countrywide to ensure registration.

On 2 November, the centre "expressed concerns about the obstacles facing election observers, including delays in finalizing their accreditation procedures and delays in election preparations, as well as continued reports of harassment of political party and civil society activity".

Citing Darfur, it warned of the difficulty of running election activities in the troubled region: "The continuing state of emergency means that a free and open electoral process remains difficult to contemplate."

Insecurity worries

Separately, the Washington-based Enough Project warned that poor preparations would impact on future key events, including the referendum on the south’s potential full independence slated for January 2011.

"The deck is stacked against a free and fair election in five months," wrote Sudan-based researcher Maggie Fick in a 5 November report. "There are worrying signs that it could be a trigger for further insecurity."

The process, she added, could, however, provide key lessons for the actual elections. The voter registration process “could also serve as a trial run in which some of the issues that could negatively impact [on] the polling period could be resolved", she added. "Alternately, the registration process could expose a reality that... has been felt on the ground for some time: these elections could destabilize already insecure areas as the all-important 2011 referendum draws nearer."

Awareness problems

In capitals like Juba, awareness is poor, despite efforts by the authorities to advertise the process through street marches, poster campaigns and radio broadcasts.

"I registered on the first day, but I know many people who are not aware," Opio Moses Korduk, a local resident, told IRIN.

Others however, said that as southerners, their concern was the 2011 referendum and not the election.

"The north cheated us when they ran the census results," said James Deng, a student at Juba University, referring to the contested national census results released earlier this year.

"So why should we think the election will be any different? I am waiting for the referendum because independence is the only future for the south," he added.

Rising tensions

Meanwhile, talks continued between north and south following meetings with the US Special Envoy Scott Gration to tackle sticking points of the CPA.

"It is a difficult and lengthy process, but failure is not an option," Gration warned in Khartoum on 2 November.

Tensions have risen between north and south, especially following comments by Southern President Salva Kiir that voting for unity in 2011 would make southerners "second-class" citizens in Sudan.

The two sides are still divided by ideological, religious and ethnic differences over which the civil war was fought.

"It is why it is critical that we ensure that the process is fair and credible and that the will of the people, as expressed through the national elections and the referendum, is respected peacefully," added Gration.

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http://www.irinnews.org/report.aspx?ReportId=86894WAJIR EAST Thursday, November 05, 2009 (IRIN) - The sound of the evening bell at a local boarding high-school in Wajir, in the northeast of Kenya, did not always signal the end of the day's classes. Instead it marked the end of the evening bathroom break as “bucket toilets” were emptied for the day. WAJIR EAST Thursday, November 05, 2009 (IRIN) - The sound of the evening bell at a local boarding high-school in Wajir, in the northeast of Kenya, did not always signal the end of the day's classes. Instead it marked the end of the evening bathroom break as “bucket toilets” were emptied for the day.

Such stories are commonly told with a mixture of humour and concern in the semi-arid region of Wajir, where most residents have little access to improved sanitation - with serious health implications.

"Wajir is prone to diarrhoea outbreaks," Francis Njoroge, Wajir East medical health officer, told IRIN. "Diarrhoeal diseases are [the] third [most] common illness in children below five years.

"Several factors could be contributory: the town lacks a sewerage system [and] uses a bucket system... people depend on boreholes... and many of the community water wells are not protected, exposing them to contamination," Njoroge said.

Outside the town, people use water from open dams, which they share with animals. "During the rainy season, run-off water washes animal waste into the dam, contaminating it," he said.

Wajir residents rely on shallow wells, due to increasing water salinity at depth, which are exposed to contamination during flash floods and from seepage.

The larger Wajir, which borders Somalia, Ethiopia, as well as the Kenyan towns of Mandera, Moyale, Isiolo and Garissa, lies in an area with large aquifers supplied by perennial rivers and dry seasonal river basins - also sources of contamination.

Like most of northern Kenya, Wajir has experienced a prolonged drought and livestock deaths. Animal carcasses litter watering points, posing a further health risk.

Contamination

Wajir South Development Association (WASDA) programme manager, Haretha Bulle, told IRIN of the challenges.

"There are [largely] no flush toilets and no pit latrines," Bulle told IRIN. A few flush toilets can be found in some hotels and in newer settlements but are rare in households.

According to a UN World Health Organization report, latrine coverage in rural Wajir is about 5 percent and just a little higher in the town.

Because of the high water table, pit latrines are not viable, and residents mainly rely on unhygienic bucket toilets - improvised from plastic jerry cans.

"Waste is collected from the bucket latrines by a tractor, which serves the whole town," Bulle noted. The town has a population of about 220,000.

"Households are not able to dispose of waste [and] are forced to dispose it anywhere," she said. "When it rains, the whole town smells. The water gets contaminated more easily and changes colour."

Refuse pit and open pit dumping is prevalent.

El Niño threat

According to Wajir town resident, Khadijah Ibrahim, ongoing El Niño-related rains will only exacerbate the situation. Her family of eight shares one bucket toilet with three other households - about 24 people in total.

"Sometimes the municipal council comes to empty the bucket after a week or 15 days. By the time the waste collectors come, the bucket toilet is already overflowing," Ibrahim said.

Her children, the youngest of whom is three, have been trained to wear shoes before going to the toilet to protect themselves, "but they only use soap to wash their hands before they eat", Ibrahim said.

Eco-toilets

The Arid Lands Development Focus (ALDEF) NGO is piloting eco-toilets, which use heat trapped by solar panels to burn human waste, reducing it to ash.

The toilets do not use water, instead relying on a dehydration/evaporation system. Diyad Hujale, ALDEF programme manager, told IRIN the target was mainly the town centre, which requires about 5,000 toilets.

Hujale recommended that Wajir town’s by-laws should make it compulsory for any upcoming construction to have an eco-toilet facility. The challenge, he said, is "how to get rid of the bucket toilet".

However, the cost of setting up an eco-san unit, about KSh60,000 (US$800), is prohibitive for private households.

Health education

Past recommendations to improve drainage and sanitation in Wajir have not yielded much, according to Bulle of WASDA. "It is one disaster after the other. When the rains come, we think of the drainage but forget about it when the drought comes."

At present, village elders in Wajir are being taught how to chlorinate the community wells, according to health officer Njoroge. Health education on the importance of protecting the wells is also being provided.

He said the construction of more toilets is being encouraged in new settlements, where communities are provided with water treatment chemicals.

"Health education is ongoing. Of importance is that there is continued disease surveillance in the district," he said. The solution lay in "providing clean water to the community and safe disposal of human waste via a sewerage system".

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http://www.irinnews.org/report.aspx?ReportId=86896NAIROBI Wednesday, November 04, 2009 (IRIN) - Encouraging the use of traditional African herbal medicines could prevent some of the one million malarial deaths on the continent, according to specialists attending a conference www.mimalaria.org/pamc in Nairobi. Many poor communities, especially in rural settings, cannot afford modern malarial drugs and many people die due to inaccessibility of treatment.NAIROBI Wednesday, November 04, 2009 (IRIN) - Encouraging the use of traditional African herbal medicines could prevent some of the one million malarial deaths on the continent, according to specialists attending a conference www.mimalaria.org/pamc in Nairobi. Many poor communities, especially in rural settings, cannot afford modern malarial drugs and many people die due to inaccessibility of treatment.

“Malaria kills many people in Africa, both children and adults, despite the availability of free treatment in certain African countries. While it is true many governments in Africa, with development partners, give free pediatric treatment for malaria, many still cannot access this facilities and resort to home treatment,” says Merlin Wilcox of the Research Initiative on Traditional Antimalarial Methods and the University of Oxford.

Some specialists at the ongoing 5th MIM Pan African Malaria Conference in Nairobi said medicines drawn from plants that abound in the continent could be utilized to save many people, especially those in poor settings, from malaria.

BN Prakash, a researcher with the Foundation for the Revitalization of Local Health Traditions, based in Bangalore, said Africa could draw on experiences in India where medicinal plants have been used with great success in the control of malaria-related deaths.

“Research in India has shown a 5-10 times reduction in malaria-related deaths among communities who use traditional medicinal plants like Guduchi [tinospore coeditdia], a local medicinal plant found in India,” said Prakash.

Preserving traditional knowledge

Another speaker, Gemma Burford of the Global Initiative for Traditional Systems of Health, said while there had been increased cases of loss of knowledge about traditional medicinal plants, student-led research could be used to preserve knowledge and create a database on these plants.

“When we carried out research involving school children in rural Tanzania about traditional Maasai medicines, we found out that 48 percent of these children already had knowledge about these plants. We used [this knowledge] to create a database for the purposes of preserving the knowledge and these plants too,” said Burford.

“It is important to note that many malarial drugs are still bought from commercial pharmaceutical shops and not many of them are that cheap. Costs also involve how easy or not it is to access these government facilities, especially in Africa where medical facilities are far-flung,” Burford said.

Educating the youth

Speakers at the conference called on African governments to introduce educational programmes that would teach the younger generations about the traditional methods of treating malaria and other diseases plaguing the continent.

“The biggest obstacle to use of traditional medicines is lack of interest from the youth and teaching them about these medicines would be the best way to let them appreciate their values. Evangelical churches and development agencies must also be persuaded to stop fighting traditional African medicine because modernity and tradition can be married to provide a formidable force against malaria,” added Burford.

Effectiveness and dangers

Doumbo Ogobara, director of the Mali Malaria Research and Training Centre, and a lecturer at the University of Bamako, said there should be more research to ensure the effectiveness of traditional medicinal plants in the treatment and management of malaria.

“More research must be directed towards finding out the effectiveness of these traditional medicinal plants and their safety and efficacy because initiatives on using them could be counter-productive if this is not done. More emphasis therefore must be laid on research for plant-based prophylactics for malaria,” said Ogobara.

Mahamadou Sissoko of the Centre called for caution in taking the traditional medicinal route, arguing that many malaria-related deaths have occurred even among communities that have relied heavily on traditional plants for treatment.

“People are dying even in places where there is still widespread use of traditional medicinal plants and unless the efficacy of a traditional plant on malarial treatment can be ascertained through vigorous research, we could have our backs against the wall. Many traditional healers will abuse this and give anything as medicine so long as it is a plant - we must urge caution,” said Sissoko.

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