Women, poverty, human rights and HIV/AIDS: Argentina. (National Contexts).

In many of the countries of Latin America and the Caribbean, the new millennium has meant a drop in living standards and an important increase in poverty which mainly affect women, children and youth. This situation is the direct consequence of the development and growth strategies pursued at the behest of international organisms such as the International Monetary Fund and the World Bank and endorsed by the developed countries. These entities promoted the consolidation of a new economic paradigm based on deregulation and the elimination of international trade and financial barriers.

However, globalization and the new economic paradigm which led to the imposition of market liberalization in our countries starting in the 1980s did not necessarily produce the expected effect. Economic integration, the indiscriminate opening of markets and the elimination of tariff barriers were supposed to lead to increased production and boost the regional share of world trade and income; however, this did not always occur. On the contrary, in countries of the region, this strategy resulted in the destruction of local industry, unemployment and an increase in poverty.

In the 1990s, Argentina was the model held up by these organisms as an example for the rest of the world to imitate in applying these policies. However, when the country defaulted on its loans at the beginning of 2002, it rapidly fell from grace. Today, as we all know, Argentina is a prime example of the result of the extreme application of these policies. If this experience has any silver lining, it is to teach us to avoid repeating this mistake and to recognize that the "recipes" of others are neither infallible nor universally applicable. As economics is a social science, it cannot offer guaranteed results. In each, specific, socio-political context, the effects will be different.

Let us consider some of the consequences for Argentina. In the first period, national production fell due to the massive importation of foreign goods. Jobs were eliminated first in the productive sector, followed by several years of job loss in the service sector. The latter survived in part through continued government spending, but with the application of structural adjustments in the 1990s, employment in services also fell drastically. Initially, unemployment hit men, who predominated in the productive sector, although certain areas such as textiles, which was one of the first to close down, had a high proportion of women workers. Women retained their jobs proportionally for a longer period because of their greater participation in the tertiary or service sector.

Unemployment grew rapidly from 1994 on, with a sharp increase in 1998. Starting in 2000, it once again began to rise. Along with the increases in unemployment and underemployment, all work became more precarious. Job security was undermined, informal work grew, wages were reduced, the work-day increased, and fringe benefits such as health coverage and social security began to disappear.

In December 2001, the country's socio-economic and political crisis sharpened; in less than six months the numbers of poor people doubled. In May 2002, according to official data, 51.4% of the population of Argentina was living under the poverty line, half of them indigent. Significantly, this situation is not equally distributed by sex and age: women and youth from 15 to 24 years old are the most affected by unemployment and poverty. Almost half of all youth in this age group neither work nor study. (1)

The rapid impoverishment of such a large percentage of the population, with women and youth predominating, generated a new outbreak of violence and insecurity. Although there are no statistical data, an increase in domestic and sexual violence has occurred which affects mostly women and girls. This increase can be observed in news coverage and in anecdotal reports from health and legal services. The number of these crimes has increased, and the level of the aggression has also risen. Intolerance is more widespread than ever. Perpetrators are younger and more aggressive and include more women.

The context of severe political instability and dissension further aggravates the socio-economic crisis and increases its negative effects, leading to deterioration of physical, psychological and social health. In this situation, human rights run the risk of being buried by the crisis. Given the gravity of the situation, governments, individuals and the populace focus only on basic survival; human rights appear to be luxuries for more normal times. The right to life once again has become the top priority and pushed social rights aside.

The right to health and sexual and reproductive rights in particular are clearly affected by this reality. The abrupt devaluation of the Argentine peso sharply raised prices of hospital supplies, leading to shortages in public hospitals, as well as in private services and those run by the workers' pension system. Many types of medical care simply were eliminated, and operations and other procedures had to be postponed. Costs increased, resulting in more direct or out-of-pocket costs for users for a variety of services, even in nominally free public facilities. In many cases, patients are discouraged and simply stop seeking health care. This deterioration is part and parcel of the crisis and affects all three health systems.

The loss of employment also meant many people lost their workers' pension benefits, including health insurance. As recently as the 1980s, 85% of all Argentines received health care through this apparatus. The enormous loss of jobs meant that by 1995 this coverage had fallen to only 50%. (2) Initially, individuals filled the gap by purchasing private health coverage which was later reduced to strictly emergency situations and finally suspended altogether. From that point on, a considerable portion of the population had to depend for health care on the already overburdened public hospitals, now used mostly by the new poor and the impoverished middle class. The structural poor and/ or destitute do not seek health care at all, except in cases of extreme emergency. Although public services are free, the long waits, the lack of money to pay for transportation and/ or the inability to pay for prescriptions discourage their use. Check-ups and preventive care are now luxuries or extravagances to be considered only after resolving more urgent survival needs. How can a mother think of vaccinating her children when she cannot even guarantee them regular meals?

Sexual and Reproductive Health 

According to the latest statistics from the Ministry of Health for the year 2000, maternal mortality in Argentina returned to the levels of 1997 (3.9/ 10,000), reversing the declines registered in 1998 and 1999. Adolescent maternity continued to rise, especially among minors under 15; this group also registered maternal deaths for the first time in 2000. (3) AIDS continues to increase among women, and by March 31, 2002 the male/female ratio in AIDS cases was 2.8:1, compared with 6.9:1 in 1991. (4) Heterosexual transmission shows a sustained increase since the beginning of the epidemic in 1982 and accounts for 64.2% of all infections among women. But heterosexual transmission also increased among men at the expense of the homosexual population, for whom the rate is descending or stabilizing. HIV tests on pregnant women--with their prior consent, following the norms for the prevention of mother-child transmission in effect since 1997--showed a rise in infections among pregnant adolescents in late 2001, indicating greater risks of infection for adolescent women.

The average age of women with AIDS (28) is lower than that of men (31); women also develop AIDS at earlier ages than men. From the start of the epidemic in 1982, a greater proportion of women under 20 were reported to be becoming ill with AIDS, although the rate is now dropping, possibly due to the availability of early treatments. Over the years, a rise in the age at which women become ill due to HIV infection has been recorded, with an increase in those over 50 years of age. (5) With respect to educational levels, considered an indirect indicator of socio-economic status, there is a lower level of instruction among women with AIDS than among men, especially compared with those infected by homosexual transmission, who tend to have higher educational levels.

With respect to mortality, since 2000 AIDS constitutes the leading cause of death in women and men from 15 to 49 years of age in the city of Buenos Aires and is the number two cause in Buenos Aires province. Nationwide, it is the third cause of death in this group. Since 1997, the Ministry of Health has provided free anti-retroviral medicines to all HIV-positive persons without health insurance. The mortality analysis between 1997 and 1999 shows a statistically significant drop in 1998 and 1999, undoubtedly due to access to these medicines. In 2000, deaths attributed to AIDS leveled off, with only a statistically insignificant increase registered in people over 45, perhaps due to lesser accessibility to health services and/or the delays related to confirming an HIV diagnosis at this age.

The current impoverishment of women and youth indicates that their already greater vulnerability to HIV infection will now intensify. At the same time, HIV infection risk will also rise as a result of the interruption in 2002 of the prevention campaign developed by the Ministry of Health for the first time in Argentina just the year before, as well as the Ministry's interruption of community prevention programs carried out throughout the country with the assistance of local NGOs. These programs backed or implemented directly by the Ministry of Health in 2000 and 2001 included the opening of almost 400 free, voluntary and anonymous HIV testing centers around the country.

Although AIDS medicines are free in Argentina, the Ministry of Health periodically experiences supply difficulties. Price increases as a result of the devaluation of the peso, as well as budgetary restrictions and logistical difficulties in 2002, created serious problems for maintaining treatment continuity in many cases.

Given this social, economic and labor context for the majority of the Argentine population, we cannot endorse the much-heralded benefits of globalization on health. Opinions such as those expressed by Giovanni Cornia, (6) are important to encourage us to research and publish our findings about the realities of our region. (7) In addition, these perspectives make us feel less alone in the world.

Activism and Leadership

In such moments of deep crisis, keeping our activism alive in defense of basic social rights such as health, education, food and employment is fundamental. Today, the voices of many people, especially socially-excluded, poor women and youth, have been extinguished or submerged in the fight for survival and our frustration at the current situation. It is precisely now that those of us who try to defend human rights must raise our voices in the name of those who cannot do so. We need to keep up the agitation and denounce abuses, focusing on basic needs. In addition, our principal responsibility is to encourage social, community and political leaders to defend human rights, especially social rights, and to make sure that public health services are meeting people's basic needs.

Sexual and reproductive health programs are today a special priority in Argentina. The risks of a pregnancy to someone who lacks the means to care for another child are very high today because access to contraceptive methods is practically impossible, unless they are provided by the State. Reproductive health programs are not present nationwide because the National Reproductive Health Law was never approved. While half the provinces in the country do have reproductive health laws, they cover only one-third of the population. If women cannot prevent these pregnancies, many--especially poor women--will resort to unsafe abortions, as is already happening and surely will increase with the ensuing risk of death. (Eds. Note: On October 30, 2002, the National Reproductive Health Law was passed, as explained in the author's brief addendum to this article.)

Prenatal care, nutrition during pregnancy, and adequate childbirth services must be provided for women to ensure the best possible conditions for themselves and their babies. They must have care not only during the birth but post-partum, as well. Attention for sexually transmitted infections, including HIV/AIDS, also is a top priority, including diagnosis, treatment and prevention. Today, AIDS affects youth and poor women more than ever; we must redouble our efforts and concentrate prevention, diagnosis and treatment efforts among these groups if we want to halt the growth of the epidemic.

Proper information on HIV/AIDS and its forms of transmission, as well as sexual and reproductive health education and free access to contraceptive methods for all women, independent of their serological status, are non-negotiable rights that should be defended and guaranteed. Another non-negotiable demand is the right to STI and HIV/AIDS treatment; this must include confidential, voluntary and free HIV testing of all women, including pregnant women, as well as treatment of HIV-positive women whether or not they are pregnant.

At the recent International AIDS Conference in Barcelona, several women's groups, coordinated by the Working Group on Women and AIDS of the International AIDS Society and the International Community of Women Living with HIV/AIDS, organized a series of meetings which produced a declaration entitled "Women and AIDS: The Barcelona Bill of Rights." The Declaration notes that more than 20 years after the beginning of the epidemic, AIDS continues to spread due to the inequalities between men and women and that the latter are the most affected.

The Barcelona conference did not produce dramatic findings or novelties. Just as at the United Nations General Assembly Special Session on AIDS in June 2001, speakers reiterated that only strong leadership and political commitment could bring the epidemic under control. Independent of the scientific program, two enormously successful parallel sessions with social, cultural and political leaders had a great impact both within and outside the Conference. Women leaders gathered at one meeting and political leaders at the other; they established a program of action to incorporate other leaders into efforts to have an impact on the epidemic. Both men and women emphasized the importance of putting an end to the inequality between men and women as a basic element in stopping the spread of AIDS, which continues to grow, principally at the expense of poor young women and girls.

At the Conference's closing session, former presidents Bill Clinton and Nelson Mandela explicitly called for putting an end to the discrimination and stigma surrounding AIDS; educating youth in the exercise of healthy sexuality; eliminating gender inequality; guaranteeing human rights for all, especially those of people living with HIV/AIDS; assuring access to treatments through price reductions and overcoming patent restrictions to facilitate generic drug production; and transferring resources from the rich countries to pay for treatments in the countries that cannot afford them. Both leaders also questioned spending on warfare which displace resources for social programs, including health. In the words of the former U.S. president: "With the money that the United States spends in two months on the war in Afghanistan, we could find the 10 billion dollars that the United Nations estimates is needed to treat and prevent HIV/AIDS in the world."

In the face of the crisis, the growing needs of women and youth, the social, economic and employment situation arising from globalization and the deterioration of health services, clear public policies oriented to meeting the basic needs of the population are urgently needed. Without a clear consensus on priorities, we will not be able to safeguard the well-being of the majority and especially of the most vulnerable, poor young women and girls.

Notes

(1.) SIEMPRO, http://www.siempro. gov.ar, published in Clarin, June 9, 2002.

(2.) Bianco, M. (1997). Fecundidad, salud y pobreza en America Latina. El caso Argentino. Buenos Aires: FEIM/UNFPA.

(3.) Ministry of Health, National Health Statistics Program (2001). Estadisticas Vitales, Informacion Basica--Ano 2000. Buenos Aires: Ministry of Health.

(4.) Ministry of Health, HIV/AIDS Unit (2002). Boletin sobre el SIDA en Argentina, Buenos Aires: Ministry of Health, March.

(5.) Ministry of Health, HIV/AIDS Unit (2001). El SIDA en Argentina. Buenos Aires: Ministry of Health, September.

(6.) Cornia, G.A. (2002). "La globalizacion y la salud: resultados y opciones," in Boletin de la Organizacion Mundial de la Salud (Geneva) 6:23-31.

(7.) Bianco, M. (2002). "Trade liberalization and sexual and reproductive health in Argentina," paper presented at the International Women's Research Center workshop, Washington, D.C.

Addendum: On October 30, 2002, the Argentine Senate finally passed the National Reproductive Health Law. This text, previously approved in the House of Deputies in 2001, creates a nationwide program in the Ministry of Health which requires sex education in schools and the provision of free services in public hospitals, as well as in the private and workers' pension systems.

The new law is more restrictive than an earlier version:

* Private schools, whether or not they are church-affiliated, can opt out of the sex education requirement.

* Church-affiliated health services are not obliged to provide sexual and reproductive health services.

Both issues should be tackled because private education is very important in Argentina, not just for children of those families with enough resources to pay for adequate medical care, but also for children of lower-income families who need this education in their schools because they are not going to have sufficient resources to obtain it elsewhere nor receive private health care.

The possibility that church-affiliated health services may choose not to offer this type of care is now important because many workers' pension and/or pre-paid health plans have cooperative agreements with these providers. As a result, many persons who do not share the religious convictions of the providers may be left without reproductive health care, even though their health plan had not informed them of this loophole when they signed the contract. In these cases, church-affiliated health providers that do not intend to offer sexual and reproductive health care must be required to identify themselves so that users can insist that their providers or insurers include an alternative in the agreement.

We must insist on these clarifications and disseminate them so that the new law can be perfected to benefit everyone who needs it.

The author is an Argentine physician and holds a Master's degree in public health and epidemiology. She is president of the Fundacion para Estudio e Investigacion de la Mujer (FEIM, Foundation for Women's Studies and Research) and coordinator of the International AIDS Society's Working Group on Women and AIDS.