Countdown 2015: Sexual and Reproductive Health and Rights for All — a conference that wrapped up in London last week — was awash with statistics on a range of matters. One statistic had particular resonance, however, namely that men in sub-Saharan Africa only have access to an average of three condoms a year.
This figure encapsulates one of the most frustrating realities faced by health workers today — the fact that there simply aren’t enough contraceptives to go around. This is despite the fact that condoms cost, on average, about three cents a unit.
While progress has been made since the International Conference on Population and Development (ICPD), about 123-million couples in the world’s poorer countries still lack access to contraception. The ICPD, held in the Egyptian capital, Cairo, in 1994, was a landmark event that aimed to make sexual and reproductive health services available to all by 2015.
In the case of condoms, which also play a major role in preventing the spread of HIV, almost 10-billion units were required in 2002 in the developing world and Eastern Europe. However, donors provided just 2,5 billion, according to the Washington-based lobby group Population Action International (PAI).
Granted, this marked an increase from the 950-million condoms supplied in 2000. But, the increase has been ascribed to what PAI calls “one-time contributions” by governments in Britain, the Netherlands and Canada — not funding that had been committed for several years to come.
In addition, these contributions must be seen in the context of a general decline in support for provision of contraceptives. In spite of the donations made by Britain and other funders, the United Nations Population Fund (UNFPA) says overall funding for contraceptive programmes fell in 2002 to almost $198-million. (By 2015, $1,8-billion will be needed to fund comprehensive contraception initiatives, says the UNFPA.)
Although the condom and contraceptive shortfall received top billing at Countdown 2015, it seems odd that it has not featured more prominently in the public arena since the Cairo meeting — when contraceptive shortages were also the order of the day. (Countdown 2015, a three-day gathering, was held to discuss the status of efforts to implement a plan of action that emerged from Cairo.)
“There are many of us who have known, for a very long time, that there are problems of not enough contraceptives,” said PAI President Amy Coen. “But remember, when HIV/Aids first came out, it took a full decade for people to even know there was this horrific pandemic happening. It’s like every other dawn on a terrible problem: the sun comes up slowly.”
As far as condoms are concerned, there may also be a deeper and more subtle interplay of issues behind the fact that they are not more readily available.
In a booklet entitled Condoms Count, PAI notes “What needs to be done (to improve condom distribution) — and how — is clear.”
“What is lacking is firm, unambiguous acceptance of the indispensable role of condom promotion in prevention (and) commitment to action — principally on the part of governments and some key donors.” the booklet adds.
It’s a trend that Frances Kissling, president of Catholics for a Free Choice, a non-governmental organisation (NGO) based in Washington, has also noted.
“I think there are two aspects to it. One aspect is a genuine, medical concern in the sense that condoms are not fool-proof. And, while the failure rate is small, the price of failure is tragic,” she said, adding “There is an uneasiness. One doesn’t want to over-endorse a condom if there is the risk.”
According to various sources, the male condom is about 98% effective in preventing pregnancy if used correctly. Studies cited on the Reproductive Health Outlook website, run by the Seattle-based Programme for Appropriate Technology in Health, indicate that condoms prevent the transmission of HIV amongst about 80% of users, and upwards.
The second aspect to ambiguity about condoms, says Kissling, relates to questions about the ethics of sexual relationships where there is a risk of a deadly disease being spread.
“I think that one of the problems that has existed, particularly over the last five years, is that there is an increasing negativity towards sexual activity in general — and sexual activity by people at risk,” she noted. “I think there are many people in NGOs as well as in government agencies who really believe that people who are at risk of transmitting HIV simply should not have sex.”
Many delegates to Countdown 2015 appeared to believe that this moral queasiness had found its clearest expression in the policies of US President George W. Bush.
While officials in the United States have endorsed the ‘ABC campaign’ (which emphasises “Abstinence”, “Being faithful” or “Using a Condom”) — something used to great effect in Uganda — it is abstinence rather than condom use which appears most attractive to them.
A $15-billion Aids package, the President’s Emergency Plan for Aids Relief (PEPFAR) that came into effect in 2003, requires a third of US funding for Aids prevention to be spent on programmes that encourage abstinence before marriage.
Coen believes this has a “chilling effect” on initiatives which deal with other areas of sexual and reproductive health.
In a speech to delegates given August 31, UN Foundation President Timothy Wirth also claimed the United States was supplanting “comprehensive family planning and reproductive health strategies by well-meaning, but far less effective and largely unproven abstinence efforts.”
A conference held in the Turkish city of Istanbul in 2001 highlighted the growing urgency of the need to close the so-called “condom gap”, and various NGOs have since joined forces over the matter. Four such groups formed the Supply Initiative, for example: a project that, amongst other things, uses the internet to help streamline the funding and procurement of contraceptives.
Kissling also believes that dogged persistence in the face of shortages is key.
“There is no magic in terms of how you create social change or political will. You simply hammer away at the facts, and you keep on advocating for what you think needs to happen,” she says. “You just push, and push, and push, and push — that’s how every social change has happened.”
As was noted at Countdown 2015, countries that are recipients of contraceptive aid also need to demonstrate a clearer commitment towards universal contraception — even though their lack of infrastructure may pose considerable challenges to ensuring timely distribution of condoms, or monitoring their use.
For Kevin Osborne, a senior advisor on HIV/Aids to the London-based International Planned Parenthood Federation, the corporate sector holds valuable lessons in this regard.
“I’m going to use the analogy of Coca-Cola. No matter where you go, you can find Coca-Cola (and) if we can get Coca-Cola to the most remote villages, then the question of infrastructure – we look at it in a different light,” he said.
If widespread distribution is possible with Coca-Cola, then why not condoms? — IPS