In a short space like this, one can only present the briefest of sketches of a multifaceted issue in a huge and complex continent. I shall not even touch on the question of homosexual rights, since that is dealt with elsewhere in this issue (see Page 12). Africa has many intractable problems and they all impact on the questions under consideration. Among them are: poverty; rapid population growth; poor infrastructure; corruption; kleptocratic and incompetent governments; war and ethnic conflicts; lack of integration with the world economy; proxy battleground for outside interests; cultural and religious practices that hold back progress; and ignorance and superstition. Of course, not all these factors are present everywhere or are equally important. Nor are they independent of one another. By poor infrastructure I don’t just mean lack of decent roads (although that has a huge effect), but also lack of efficient legal structures and lack of social investment. And even a rich country would struggle to keep up with providing the infrastructure needed for a population that was doubling in only thirty years, as many in Africa are. For a poor country, it is very difficult to raise standards even for their present population, never mind the millions being added every few years. Rapid population growth also tends to produce high unemployment and competition for resources, thus often fuelling conflict. Corruption and bad government are like very inefficient taxation. Efficient taxation, while always painful for the taxed, at least raises money that can be ploughed back into building up infrastructure or meeting present needs. The totally inefficient taxation represented by corruption simply funnels money away from where it is most needed. If one looks at figures for per capita Gross Domestic Product (GDP), one sees very low figures for a majority of African countries, particularly those in sub-Saharan Africa. For example, it is about $1500 for Nigeria, an oil producer. But this is only an average; many people earn much less than this, while some are almost obscenely rich. Billions of dollars have been stolen from the people by their erstwhile rulers. At least Nigeria has an Economic and Financial Crimes Commission [1], which does appear to try to redress some of the problems. So what does this lack of infrastructure mean for sexual and reproductive health? It means insufficient investment in and provision of primary health care. Let us look at Burkina Faso, for example. Although very poor by the standards of developed countries, its GDP of around $1200 is about double that estimated for Malawi. So in terms of sub-Saharan Africa, it is nowhere near the bottom. Its population is growing at just under 3 per cent per year. This rate, if it continues, will lead to a doubling in about 25 years. It is spending about 2.6 per cent of GDP on public health. This is, of course, a tiny amount in money terms. It is interesting to compare Burkina Faso’s figures for those from South Africa, by far the most developed country in sub-Saharan Africa, and with those from, say Spain, a European developed country well below the highest levels of income. (See Table in Box 1.) No figures are available for Spanish births with skilled attendants, but we can be sure that the figure will be near 100 per cent. For such a poor country, Burkina Faso at 57 per cent is not doing too badly in this respect (the corresponding figure for Ethiopia is 6 per cent!). Nevertheless, it still has a very high maternal mortality rate. Some of this may be explained by other factors, such as the high prevalence of female genital mutilation, a known risk factor, and child marriage, another. Another striking figure in this table is the high prevalence of HIV infection in South Africa. Unfortunately, the Government must take some of the blame for this. President Mbeki is an HIV denier: he does not believe that HIV infection causes AIDS. The Government has therefore delayed the energetic intervention that could have saved thousands of lives. Elsewhere in sub-Saharan Africa there is a great deal of ignorance and denial about HIV/AIDS. This is the continent where HIV is thought to have originated, and responses to it are very variable. Some countries such as Uganda have taken fairly effective measures against this scourge. The famous ABC campaign (Abstain from unsafe sex, Be faithful, use a Condom), provided a simple and effective method of fighting this horrible disease, and has been copied elsewhere. Fighting HIV/AIDS gives a picture of a number of the problems that beset much of Africa. A dangerous cocktail of ignorance, superstition and religious prejudice has hampered the HIV/AIDS campaign. Myths abound about the causes of disease and the possible remedies. The Roman Catholic Church has been responsible for circulating false rumours about condoms. The USA has been a generous donor to the campaign, but its own internal religious politics have impacted on the effectiveness of its donation. Instead of ABC, it has recently concentrated on the A – abstinence only. Abstinence is simply not a choice for many African girls and women. South Africa has very high levels of rape, for example. Countries that are riven by conflict also have huge rape problems. Other countries have problems like child marriage, which also increases female vulnerability to HIV. Many African girls and women are subject to inequality and abuse. They often find it difficult to access contraception or safe abortion, and unsafe abortion is still a major killer of women in poor countries, particularly in sub-Saharan Africa. Maternal deaths in general are very high in many African countries, and for every woman who dies as many as 30 may suffer chronic illness or disability. Many measures are needed to improve their lot. It is well known that improving women’s education can lead to better health for their families. Informed mothers are better than ignorant ones. And educated girls tend to marry and give birth later, helping to slow the population increase. Both boys and girls also need sex education, so that they can cast aside old myths and taboos and understand the workings of their bodies, defending themselves against infections and unwanted pregnancies. Better care of pregnant women and their infants can save lives. Training traditional birth attendants is often a fairly cheap measure to help bring down maternal mortality. Giving women access to contraception can help them to space their births, leading to improved maternal and family health. The big question when one looks at a list of woes like the above is “What can be done?” The Millennium Development Goals, if they are met, are designed to make a significant improvement. But it is highly doubtful that they will be met. Africa is mostly poor, so aid is still essential, but so is reform. Donor countries have not in general met their previous pledges at ICPD [2], although there are some notable exceptions, such as the Netherlands, Norway, Luxembourg and the United Kingdom, contributing an average of $400 per million dollars of gross national income [3] (GNI) in 2003. The United States, in comparison, gave just $165 per million dollars of GNI. ICPD did not envisage the scale of spending that would be demanded by the HIV/AIDS epidemic. This has swallowed up much of the funding available for sexual and reproductive health, so that family planning has actually suffered a reduction in spending in some areas. There is no doubt that dealing with corruption and poor government would also free funds for social purposes such as education and reproductive health. This is not something that can easily be helped by outside intervention. Africans need to find ways of dealing with it themselves. Africa’s strength lies in its people. Yes, there are disgraceful “leaders” such as Mugabe, Abacha and al-Bashir, but there are also shining lights. Some of the most inspiring speeches I have ever heard on the subject of reproductive health and women’s rights were from Ghana’s Professor Fred Sai: warm, humane, charismatic and erudite, and able to electrify an audience of blasé professionals. And then there are the ordinary women activists – often people of limited education but great strength of character – who have decided to make a change in their own community. When I meet people like this, I am inspired to hope. [International Humanist News from time to time carries articles about groups of Humanists in developing countries who are helping themselves and others. Humanist groups in richer countries can help them make a difference by taking an interest and raising money for them. Please get in touch with IHEU if you have a group that wants to help. Ed.] 1 http://www.efccnigeria.org/ 2 International Conference on Population and Development, Cairo 1994. 3 GNI is GDP + so-called “invisible earnings”. Diana Brown is a lifelong Humanist with a particular interest in human rights

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	Spain	South Africa	Burkina Faso
GDP (purchasing parity $)	25820	12120	1220
Population annual growth rate (%)	0.4	0.2	2.9
Government expenditure on health (% total GDP)	5.5	3.2	2.6
% births with skilled attendants	No data	84	57
Maternal mortality (per 100 000 live births)	4	230	1000
Infant mortality (per 1000 live births)	4	39	116
Contraceptive prevalence (%)	81	56	14
HIV prevalence (M/F % of aged 15—49)	0.9/0.3	15.0/22.5	1.6/2.4