How governments should address sex work is a major topic of debate in Rwanda and other countries. Some constituencies propose harsher punishment of sex workers as the cornerstone of an improved policy. The authors of this paper argue that an adequate policy response to sex work in the Rwandan context must prioritise public health and reflect current knowledge of the social determinants of health. This does not imply intensified repression, but a comprehensive agenda of medical and social support to improve sex workers’ access to health care, reduce their social isolation, and expand their economic options. Evidence from social epidemiology converges with rights-based arguments in this approach. Recent field interviews with current and former sex workers strengthen the case, while highlighting the need for further social scientific and epidemiological analysis of sex work in Rwanda. Rwanda has implemented some measures that reflect a rights-based perspective in addressing sex work. For example, recent policies seek to expand access to education for girls and support sex workers in the transition to alternative livelihoods. These policies reinforce the model of solidarity-based public health action for which Rwanda has been recognised. Whether such measures can maintain traction in the face of economic austerity and ideological resistance remains to be seen.
Values, Policies and Rights
Public health practitioners and theorists are diverse and have various social goals that they promote, but the unique status of public health can be traced to the fact that most of what it has historically concerned itself with can be classified as the provision of health-related public goods, the author of this paper argues. He asserts that a public goods framework serves as a useful criterion for distinguishing public health from private health, and it explains why public health goals have special urgency. Public health goals, properly understood, generally require collective action to achieve, and can be endorsed by a wide variety of moral and political theories. The public goods account has the further advantage of establishing a relatively clear and distinctive mission for public health. It also allows a consensus of people with different comprehensive moral and political commitments to endorse public health measures, even if they disagree about precisely why they are desirable.
In this statement, a number of international non-governmental organisations (NGOs) working in health express their support for the report by the United Nations (UN) Special Rapporteur on the right to health. They believe the report is of fundamental importance in securing the right to health, in particular because it consolidates years of health and human rights legal analysis, supporting the conclusion that criminal law is an inappropriate tool for regulating sexual and reproductive health matters. Empirical evidence demonstrates that the misuse of criminal laws and punitive policies in the area of sexual and reproductive health cause disproportionate suffering for women; people engaging in same-sex sexual conduct; people identified as lesbian, gay, bisexual and transgender persons; those living with HIV or AIDS; and other groups who already suffer discrimination. The NGOs support the report’s call to immediately decriminalise abortion, ensure access to a full range of modern contraceptive methods, and facilitate access to full, complete, and accurate information on sexual and reproductive health.
The number of abortions among women older than 18 has increased steadily over the past two years in the Western Cape Province, according to South African Health MEC Theuns Botha. Responding recently in the legislature on the impact that illegal abortions have on public health care facilities, Botha said such abortions continued to take place, despite the legal service that was offered at more than 30 health care centres in the province. While health care facilities had treated a number of women with complications arising from illegal abortions, Botha said it was difficult to say how many cases there had been as those known to the department were only of women who volunteered the information during treatment. According to the latest figures from the National Health Department, between 1997 – when legal termination of pregnancy was introduced – and last year, about 702,354 abortions were performed at public health care facilities nationwide. About 528,000 of these involved teenagers. Health Minister Aaron Motsoaledi expressed concern about the number of teenagers who were having abortions, arguing this was proof that young people were engaging in unprotected sex and risking HIV infection. A spokesperson from Marie Stopes – a non-profit organisation offering reproductive health services – called on parents and teachers to talk openly about contraception, saying that research showed that most pregnant teenagers are in poor communities where educational and financial opportunities are limited. Women need to be made aware that abortion is not a form of contraception, she said.
The Rio Declaration is the outcome document of the World Conference on Social Determinants of Health, held from 19-21 October 2011 in Rio de Janeiro, Brazil. In the Rio Declaration, heads of government, ministers and government representatives reaffirm their commitment to take action on social determinants of health to create vibrant, inclusive, equitable, economically productive and healthy societies, and to overcome national, regional and global challenges to sustainable development. They recognise that the current global economic and financial crisis urgently requires the adoption of actions to reduce increasing health inequities and prevent worsening of living conditions and the deterioration of universal health care and social protection systems. They offer specific actions under the following common objectives: to adopt better governance for health and development; to promote participation in policy-making and implementation; to further reorient the health sector towards reducing health inequities; to strengthen global governance and collaboration; and to monitor progress and increase accountability. In the declaration, signatories call upon the World Health Organisation, United Nations agencies and other international organisations to advocate for, co-ordinate and collaborate in the implementation of these objectives.
According to this statement by Latin American social medicine and civil society organisations at the World Conference on Social Determinants of Health, the fundamental cause of the inequalities within and between nations is the neoliberal economy, infused with an exclusively speculative desire for unlimited profit. Capitalism grabs profits and socialises losses, they argue, resorting to new and crueler neoliberal measures that further reduce the fundamental social rights of people. There are abundant resources for all of us on the earth, but the ‘logic’ of the market prevents people from obtaining what they need. In the area of public health, neoliberalism translates into the commercialisation of life, legal protections for intellectual property for the benefit of the medical industrial complex, control of the media in order to create ‘need’ through shock, damage to public health systems, manipulation of civil society, multiple forms of violence and other strategies to colonise the ‘collective thought’. The current dominant societal model, using the lifestyle of affluent Americans as a basis, they argue is not sustainable. The statement concludes with a call for the establishment of global alliances between progressive governments and social movements, and meaningful social participation, as well as support for the creation and consolidation of health systems and social security systems that are universal, free, integral, and public, with coverage for all people for all services.
This study explores and describes the views of drivers and conductors on the causes of workplace violence (WPV) and ways of preventing it in the road passenger transport sector in Maputo, Mozambique. The design was qualitative. Participants were purposefully selected from among transport workers identified as victims of WPV in an earlier quantitative study, and 32 transport professionals were interviewed. The triggers and causes of violence included fare evasion, disputes over revenue owing to owners, alcohol abuse, overcrowded vehicles, and unfair competition for passengers. Failures to meet passenger expectations, e.g. by-passing parts of a bus route or missing stops, were also important. There was disrespect on the part of transport workers, e.g. being rude to passengers and jumping of queues at taxi ranks, and there were also robberies. Proposals for prevention included: training for workers on conflict resolution, and for employers on passenger-transport administration; and promoting learning among passengers and workers on how to behave when travelling collectively. Regarding control and supervision, participants expressed the need for the recording of mileage and for the sanctioning of workers who transgress queuing rules at taxi ranks. They also requested that police or supervisors should prevent drunken passengers from getting into vehicles, and said drivers should refuse to go to dangerous, secluded neighbourhoods. Finally, participants called for an institution to judge alleged cases of employees not handing over demanded revenues to their employer.
In response to the Rio Political Declaration at the World Conference on Social Determinants of Health held from 19-21 October in Rio de Janeiro, Brazil the International Federation of Medical Students’ Associations (IFMSA) delegation raised issues that the Declaration failed to address. In their statement, they recognise the Rio Declaration as a major step in the quest for global health equity, but point to its failure to explicitly indicate how the unfair distribution of power, resources and wealth will be addressed, especially by United Nations (UN) Member States, arguing that leaders have missed an opportunity to make a strong statement on this. IFMSA believes that democracy is the key instrument in fixing the existing imbalances in power and in ultimately reducing health inequities, but the Declaration does not emphasise the value of democracy in all processes – from decision-making to evaluation – and at all levels – from community to global level. IFMSA also notes that the Declaration fails to specifically define the role of the private sector in reducing health inequities and does not clearly draw the lines governing engagement between government and the private sector, nor does it demand that global economic governance institutions, such as the International Monetary Fund, the World Trade Organisation and the World Bank, adhere to the same standards of transparency, accountability and democracy as those urged of UN Member States. In addition, the Declaration is silent about how tackling health inequities will be financed, making no mention of innovative financing schemes such as progressive taxation on capital gains or extremely-high earners, a financial transactions tax or the prevention of tax evasion. Although the Declaration recognises the importance of engaging with civil society, it does not advocate for the creation of spaces for dynamic dialogue that will enable civil society to be heard, reflecting the fact that civil society was excluded from the official process of developing the Declaration. Finally, IMFSA notes that the Declaration does not explicitly mention the inclusion of young people and youth organisations in the movement for action on social determinants of health.
Botswana should decriminalise homosexuality and prostitution to prevent the spread of HIV, says ex-President Festus Mogae. Mogae, who heads the Botswana government-backed Aids Council, said it was difficult to promote safe sex when the two practices were illegal. He also called for condoms to be distributed in prisons. His views are controversial as many conservative Batswana frown upon homosexuality and prostitution. Yet Botswana has one of the highest HIV rates in the world - 17% of the population is HIV positive. Mogae asserted that homosexuals were Botswana citizens and entitled to the same rights as heterosexual citizens. He said the government's failure to give prisoners' condoms was worsening the HIV and AIDS pandemic. However, a government spokesman on HIV and AIDS said that homosexuality and prostitution would remain illlegal until the government concluded wide-ranging consultations to see whether there was a need to change the law.
In this declaration by health civil society organisations from around the world, Peoples Health Movement insist that real power be trabsferred to communities to deal with the social determinants of health. A call is made for United Nations Member States and the World Health Organisation to take action around ten key areas affecting the social determinants of health. 1. Implement equity-based social protection systems and maintain and develop effective publicly provided and publicly financed health systems that address the social, economic, environmental and behavioural determinants of health with a particular focus on reducing health inequities. 2. Use progressive taxation, wealth taxes and the elimination of tax evasion to finance action on the social determinants of health. 3. Recognise explicitly the clout of finance capital, its dominance of the global economy, and the origins and consequences of its periodic collapses. 4. Implement appropriate international tax mechanisms to control global speculation and eliminate tax havens. 5. Use health impact assessments to document the ways in which unregulated and unaccountable transnational corporations and financial institutions constitute barriers to Health for All. 6. Recognise explicitly the ways in which the current structures of global trade regulation shape health inequalities and deny the right to health. 7. Reconceptualise aid for health from high-income countries as an international obligation and reparation legitimately owed to developing countries under basic human rights principles. 8. Enhance democratic and transparent decision-making and accountability at all levels of governance. 9. Develop and adopt a code of conduct in relation to the management of institutional conflicts of interest in global health decision making. 10. Establish, promote and resource participatory- and action-oriented monitoring systems that provide disaggregated data on a range of social stratifiers as they relate to health outcomes.