Insight: Lifting the veil on Afghanistan's female addicts

KABUL (Reuters) - Anita lifted the sky-blue burqa from her face, revealing glazed eyes and cracked lips from years of smoking opium, and touched her saggy belly, still round from giving birth to her seventh child a month ago.

"I can't give breast milk to my baby," said the 32-year-old Anita, who like other women interviewed for this story, declined to give her full name. "I'm scared he'll get addicted

She was huddled with other women at the U.N.-funded Nejat drug rehabilitation center in the old quarter of Kabul, having sneaked out of her home to avoid being stopped by her husband from going outside alone.

With little funding and no access to substitution drugs such as methadone, treatment is rudimentary at Nejat for a problem that is growing in a dirt-poor country riven by conflicts for more than three decades.

Afghanistan is the source for more than 90 percent of the world's opium, which is used to make heroin, and more of it is being grown than ever before.

While it is not uncommon to see men shooting up along the banks of the dried of up Kabul riverbed in broad daylight, women in the ultra-conservative culture of Muslim Afghanistan are expected to stay out of public view for the most part. They often have to seek permission from a male relative or husband to leave their home, and when they do they are encased in the head-to-toe burqa.

"I am not allowed to leave home for medical checks. What can I do? I am a woman," Anita said matter of factly.

Like many of Afghanistan's female drug users, Anita picked up the habit from her husband.

Like other women interviewed for this story, Anita asked that only her first name be used. Shrouded in stigma, female drug users is a topic that is almost never mentioned in Afghanistan.

They agreed to tell their stories to a reporter only through an intermediary they trusted.

CONSUMPTION ON RISE

Opium poppy cultivation in a country that has been growing the plant for a thousand years increased 7 percent in 2011 from the year before, due to a spike in prices and worsening security, according to a survey sponsored by the United Nations Office on Drugs and Crime.

In 2011, the farm-gate value of opium production more than doubled from 2010 to $1.4 billion and now accounts for 15 percent of the Afghan economy, the UNODC says.

Opiate consumption in Afghanistan, where it has long been a medication but in recent years has been used increasingly for recreation, is also on a sharp rise. The UNODC says Afghanistan has around one million heroin and opium addicts out of a population of 30 million, making it the world's top user per capita.

No estimates are available on how many women are addicted to opium or heroin. Nejat estimates around 60,000 women in Afghanistan regularly take illegal drugs, including hashish and marijuana.

"There has been a definite increase amongst women drug users over the last decade," said Arman Raoufi, director of harm reduction for women at Nejat.

Smoking opium costs around 200 Afghanis a day ($4), a very expensive habit in a country where a third live beneath the poverty line. Women send their children to collect scrap and bottles to help pay for their habit, or resort to begging, extending a hand to cars from beneath their burqa on busy streets when their husbands have left home.

"My husband took on a second wife and began to ignore me, so I started to smoke his powder (opium) and now must beg," said Fauzia, 30, a petite mother of five sitting in the corner of Nejat, her embroidered floral slippers poking out from under her baggy trousers. She said she was terrified that her husband and male relatives might discover she was seeking treatment on her own at the center.

Treatment options are sorely limited. A pilot project launched two years ago by Medecins du Monde, which gives methadone to drug addicts, is the only one in the country.

The National AIDS Control Programme (NACP) wants to roll it out across the country, but the Ministry of Counter-narcotics has objected, saying it would introduce yet another narcotic onto the black market.

IRANIAN CONNECTION

With her five-year-old son tugging on her unwashed burqa, 30-year-old Najia said she has smoked opium for nine years.

"It is so hard for me. I have kids. I'm poor. I'm not able to work -- my husband won't allow me," said the raven-haired mother of four.

Najia said she picked up the habit from her husband after he returned from his job as a laborer in neighboring Iran.

Raoufi at the Nejat center says the return of migrant workers and refugees, who fled to Iran and Pakistan during the Soviet occupation of the 1980s, and the bloody civil war and Taliban rule that followed, is the main reason behind the rise in female drug addicts.

Increased street prostitution since the fall of the Taliban, which policed the trade more rigorously than the government does today, has also contributed, he said.

Iran has the second highest heroin abuse rate in the world after Afghanistan, according to UNODC. Afghan addicts among the 1 million refugees in Iran have become such an issue Tehran has started to expel them.

"Our relatively open borders are not doing us any favors," said Feda Mohammad Paikan, who heads the NACP working under the Afghan Ministry of Public Health. "Most addicts get hooked in Iran, and many of these men have wives."

PRISONERS OF HABIT

Afghanistan's female narcotics problem is now filling the country's largest women's prison, Badam Bagh or "Almond Orchard", on the outskirts of Kabul.

Of its 164 inmates, 64 are opium and heroin users, double what it was when the clinic started in 2008, said clinic doctor, Hanifa Amiri.

"There are simply more drugs out there available to women now," she said, waving a medical-gloved hand over a prison courtyard, where burqa-clad female relatives were bringing gifts of pomegranates and flat naan bread for the inmates.

With cropped black hair, a leather jacket and a henna tattoo of a scorpion on her hand, inmate Madina looks nothing like an ordinary Afghan woman.

One of seven injecting heroin users in Badam Bagh, she lives with her teenage son and daughter in prison, where she has been for seven years since she killed her husband.

She said she murdered him after he forbade her from prostituting herself to support her habit, said Madina, the only inmate at the prison who agreed to speak to Reuters.

"I would love to give it all up, but how am I meant to, as a woman?" the 37-year-old mother of two said as she scratched at the scabs on her arm, dark red from recent use.

She supports her habit by selling handmade sexual aid tools -- stuffing compacted wool into condoms -- to other inmates, several of whom have developed lesbian relationships.

HIV and AIDS is becoming a more serious issue, largely spurred by injecting drug use, and could reach the general population if not tackled properly.

A new strategy being rolled out by the health ministry to target more women in counseling and HIV testing is being met by opposition from the strong conservative forces in Afghan society.

"HIV and drug use are viewed as evil in Muslim society, and even more so for women," said specialist Mohammad Hahn Heddait, who works at the infectious diseases hospital under the ministry of health.

(Reporting by Amie Ferris-Rotman; Editing by Michael Georgy and Bill Tarrant)

Researchers unveil global plan in TB vaccine hunt

Researchers on Tuesday unveiled a blueprint to guide the next steps in the hunt for a more effective vaccine against tuberculosis as the world's most advanced clinical trial nears its end.

The plan is part of a global push aimed at giving TB research the same high profile -- and funding -- that goes to diseases like AIDS.

"A blueprint has been developed, essentially a document onresearch plans for the next five to 10 years," said Hassan Mahomed, who heads clinical trials for the South African Tuberculosis Vaccine Initiative.

The fresh impetus to the research comes as scientists await the release in early 2013 of results from the world's most advanced TB vaccine trial -- one of 12 currently underway.

"That's quite an exciting development, because for the first time we will know if any of these newvaccines will have positive developments for preventing TB," Mahomed said.

Even if that vaccine proves unsuccessful, scientists are eagerly watching the results for critical insights into how to develop other vaccines.

The new blueprint sets international guidelines on how to compare the efficacy of TB vaccines, and looks forward to the next phases in development, when any viable vaccine would need to be licensed and distributed.

"To eliminate TB, we need to find a vaccine and there is still a lot to be done before we reach that stage," said Gavin Churchyard, chief executive of the Aurum Institute, a research group in Johannesburg.

"We aim to halve the burden of infection and death by 2016. New vaccines could significantly advance the fight against TB in both HIV positive and HIV negative patients," he said.

A vaccine was developed 90 years ago, but it only protects children against some forms of the disease. Adults who develop TB must undergo drugs for treatment, but new drug-resistant forms of the disease have confounded doctors.

The disease preys on weakened immune systems, so it has become a major scourge in South Africa which has one of the world's highest HIV levels, with 18 percent of adults infected.

That has made the country a key testing ground for vaccine research, hosting six clinical trials.

Once known as "consumption" for the slow wasting away of terminally-ill patients, one out of every three people is thought to be infected by the airborne TB organism, though only a fraction go on to develop the disease.

Malnutrition 'puts 450m children at risk of stunting'

About 450 million children will be physically and mentally stunted over the next 15 years unless the world takes action to tackle malnutrition, a report from Save the Children warned Wednesday.

Every hour, 300 children die due to a lack of nutrients in their diet, while those who survive are permanently damaged in a way that impacts on their lives and the economic prospects of their countries, the British charity said.
The problem has become urgent due to volatile food prices, economic uncertainty, climate change and demographic shifts.

In Asia, for example, where 100 million children are stunted, the report predicts that climatic changes to food yields will result in seven million more stunted children by 2050.

"The world has made dramatic progress in reducing child deaths, down from 12 to 7.6 million, but this momentum will stall if we fail to tackle malnutrition," said the charity's chief executive, Justin Forsyth.
He urged the British government to lead a push to reduce malnutrition with a world hunger summit later this year, taking advantage of the presence of many world leaders in London for the 2012 Olympic Games in July and August.
"Every hour of every day, 300 children die because of malnutrition, often simply because they don't have access to the basic, nutritious foods that we take for granted in rich countries," Forsyth said.
"By acting on hunger and malnutrition, world leaders have the chance to change this for millions of children across the world."
Save the Children said there were some straightforward remedies, including fortifying foods with vitamins and minerals and promoting breastfeeding.
But the scale of the challenge is highlighted in one case study. Nine-year-old Maritu from Ethiopia told the researchers that her meals consist of a small piece of flatbread with a basic sauce.
"We don't eat anything else -- I might get egg or meat once a year for special occasions. There isn't enough, but my parents give me whatever is available," she said.
A child's body adapts to the long-term lack of nutrients by giving priority to the needs of vital organs and functions rather than to physical or cognitive growth -- and the damage is largely irreversible.
Malnourished children are more susceptible to disease and the report estimates that in countries where the problem is worst, malnutrition is the underlying cause for a majority of deaths by diarrhoea, malaria and pneumonia.
The economic impact is also significant, with adults who were malnourished as children predicted to earn at least 20 percent less than the average.
In countries where half the world's malnourished children live, one in six parents also said that their children were skipping school to work for food.

Prepaid college plans: shrinking options, rising risks

(Reuters) - Jim and Celeste Durkin thought when they began investing six years ago in Illinois state's prepaid college savings plan that they were locking in a bargain price if their daughter Caroline, who is now 10, eventually attended the University of Illinois.
That might not be the case. The plan took some risky bets on private equity and hedge funds and is now 30 percent underfunded and temporarily closed to new investments.
"It was highly recommended by investment professionals and people we knew, and with all of the uncertainty in the markets we thought it was a safe investment," Durkin said.

An Illinois state representative, Durkin is determined to do something about it: He expects to introduce legislation this month to make the plans more transparent.
The Illinois plan is in worse shape than most prepaid plans, but it isn't unusual in facing problems. Prepaid plans, popular college savings vehicles offered at one time in about 20 U.S. states, are increasingly running on empty.
About half of them have stopped taking new money, according to Savingforcollege.com, and many of the rest are struggling. It means that the majority of Americans, including those in places such as Illinois and Tennessee, don't have access to a state plan, and the minority who do need to be very wary.
Declining market returns and rising tuition costs have been creating an unsustainable funding gap for the plans ever since the dotcom bust in 2000-2001. The financial crisis and its aftermath only made it worse.
Since the end of 2000, the S&P 500 stock index dropped 3 percent while tuition and fees at a public four-year school when adjusted for inflation climbed on average 72 percent in the last decade, according to the College Board, and financially strapped states have in many cases reduced or frozen funding for education.
It all means that at a time when families are particularly rattled by the volatility and low returns of financial markets and want the security of a prepaid plan, the college savings vehicles have become more expensive and higher risk than consumers realize.
Many states have significantly raised the amount consumers need to contribute to keep up with potential tuition hikes, and most don't guarantee the money will be available in the plans they oversee when the time comes to send junior to college.
Worst-case scenario - parents think they have paid for future college costs and then are suddenly told the money isn't all there, or even that the plan has collapsed because of investment losses (though that hasn't happened yet), and they have to make up the difference.
"People need to read the fine print and understand what kind of guarantee their plan really offers," said Andrea Feirstein, a consultant to college savings plans.
A HISTORY OF DIFFICULTIES
Almost all U.S. prepaid plans are a type of so-called 529 college savings plan, which allow American parents to save for college costs without paying federal tax on investment returns if the assets are used for higher education expenses. Prepaid plans are professionally managed and allow families to lock in future tuition payments for universities in a particular state.
For example, a family could set a tuition rate for colleges within the state's boundaries at $40,000 for four years when a child is five years old and spend the next 12 years contributing that. If the four-year course costs $60,000 when the child gets to college, the family still only pays $40,000, and will save $20,000.
But while there may have been great bargains like that in the past, they are becoming rare.
Ohio, for example, closed its prepaid plan to new investments at the end of 2003 because actuaries anticipated potential shortfalls as investment returns slipped and tuition at public universities soared after the state lifted a lid on fees.
The decision was extremely difficult, said Jackie Williams, former executive director of the Ohio Tuition Trust Authority and former chair of the College Savings Plans Network. At the time, "We had money rolling in, everyone was looking for a guarantee in a time of uncertainty," she said.
While some states like Texas are putting the onus on state colleges to fund shortfalls, others are making consumers pay significantly more.
"The question for most prepaid plans is that if tuition keeps rising, who is going to pay?" said Betty Lochner, director of Washington state's prepaid plan, the $1.9 billion Guaranteed Education Tuition Program. "Is it going to be the taxpayers, the universities or the consumers?"
In Washington, the answer right now is consumers. When the state legislature agreed to temporarily lift a 7.5 percent tuition cap, tuition immediately soared 19 percent. So the plan had no choice but to increase pricing for a year of tuition to $16,300 from $11,700 if a parent wants to enroll their child now.
Lochner hopes that tuition costs will level off and additional big hikes won't be necessary but the equation is a delicate one. "The question is at what point is your pricing too high and when will people stop paying," she said.
Another issue is that often families are under the impression that they are locking in current tuition prices, which is rarely the case, experts said.
"A surprising number of these plans don't tell you how their pricing compares to current tuition prices," said Joe Hurley, founder of Savingforcollege.com. "Everyone assumes they are getting it at current tuition prices and that's just wrong."
Hurley said most states are charging amounts above current prices. For example, in Washington state, today a parent would be locking in tuition at $16,300, while the current University of Washington rate is $10,346 a year.
To make such payments worthwhile, tuition costs will have to continue to skyrocket. Also a child would need to be ineligible for significant grant and scholarship funds, which could reduce the cost of a year's college for the parents.
DON'T ASSUME IT'S GUARANTEED
Fees aren't the only problem. Even prepaid plans that use "guaranteed" in their names, such as Pennsylvania's "529 Guaranteed Savings Plan," are not always backed by the state, meaning if the investments go sour, investors could potentially lose everything.
So far, that hasn't happened since most plans invest conservatively, but it is a possibility, particularly for families like the Durkins whose child won't be in college for some years. Investors are largely unaware of this risk. "In a prepaid program the only meaningful guarantee is if it is guaranteed by the state," said Len Wiser-Varon, a partner at Mintz, Levin, Cohn, Ferris, Glovsky and Popeo LLP, who advises the Massachusetts Educational Financing Authority.
Massachusetts, Florida, Mississippi and Washington are the only four states that guarantee their plans through full faith and credit of the state, meaning that if the plan goes bust, the state has to pay the promised tuition amount. The Texas plan is guaranteed by the state universities and colleges.
The plans run by Pennsylvania, Nevada and Michigan are "backed" only by the assets in the trust. If those assets are depleted due to risky investing or an "unpredicted" market event, investors may be out of luck, Levin said.
Then there are those plans, like the ones run by Maryland, Virginia and Illinois, which require legislative action for the state to pay back investors in the event of a funding shortfall. But experts said that doesn't necessarily mean funds are guaranteed because in states like Illinois and Maryland, lawmakers are only required to consider passing a law backing an underfunded plan, but not required to pass such a law.
For example, the Illinois plan - which should be able to make tuition payments for the next decade, according to a recent actuarial report - is backed by a "moral obligation." That means if the plan cannot meet its obligations, the governor would need to request funds from the General Assembly. But lawmakers do not have to support the request, said John Samuels, a spokesman for the Illinois Student Assistance Commission, which oversees the plan.
And given the current financial straits of many states, with cuts likely to balance the budgets in the next two years, getting that support won't be easy.
Virginia's plan comes closer to providing a full guarantee in that state law provides a financial guarantee in each year's budget to cover its plan in the event of a shortfall, which can only be changed by the General Assembly. And even that is subject to a veto by the Governor.
Illinois is not the only prepaid savings plan to run into trouble. In Alabama, families brought a class action suit over their plan, which was underfunded after tuition rose faster than expected and market returns plummeted. In July, a judge approved a settlement under which the plan would pay only the 2010 tuition rate, leaving families to make up any shortfall. The state supreme court has yet to rule on an appeal.
Few parents realize that the management of some plans are allowed to invest a big portion of the assets in higher-risk assets, such as hedge funds and private equity vehicles.
According to the Illinois plan's investment policy statement, its target allocation to alternative investments is 47 percent. The current allocation is 48.7 percent, said Samuels. "Anything above 20 percent in alternatives seems high given that these investments are not as liquid as others," said Feirstein, the 529 consultant.
The plan's external investment advisory panel has recently been reorganized and held its first meeting on December 29. "The Commission has made it clear that increasing transparency and developing a new investment policy are top priorities," Samuels wrote in an e-mail.
Kim Godden, a 38 year-old lawyer, started investing in the College Illinois! Plan when her daughter, Hannah, was born in 2007. Having put herself through both college and law school, it was very important to Godden to be able to pay for her daughter's education. "I am paying back my loans now and I didn't want that for my daughter," she said.
The College Illinois! Plan seemed like the perfect way for her to put money aside. "The plan was marketed as a sure thing," Godden said. "Now I am worried that the plan will go broke two years before my child goes to college."
(Reporting by Jessica Toonkel, editing by Jennifer Merritt, Jilian Mincer, Martin Howell)

Recession-hit U.S. health spending barely rose in 2010

WASHINGTON (Reuters) - U.S. healthcare spending barely rose in 2010 from record-low recession levels, as high unemployment and the loss of private health insurance forced many Americans to delay or forego medical treatment, government officials said on Monday.
Spending edged up 3.9 percent, bringing the total size of the U.S. healthcare system to $2.6 trillion, or $8,402 per person, according to a report released by the U.S. Centers for Medicare and Medicaid Services, or CMS, and published in the journal Health Affairs. For a graphic, see: http://link.reuters.com/but85s
Growth in 2010 was only a slim 0.1 percentage point higher than
the 3.8 percent recorded in 2009, which was the lowest rate recorded in half a century. Per capita health spending in the United States is still the highest worldwide.
"It's absolutely clear what's going on," said William Galston of the Brookings Institution. "People's budgets have been hard-hit, and even if they have 20 percent co-pays from their insurance companies, that 20 percent may still be too much."
The data are likely to play prominently in the political debate over U.S. government spending as President Barack Obama's 2010 healthcare reform law approaches challenges from the Supreme Court and he fights for reelection in November.
The healthcare industry's share of the U.S. economy was unchanged for the first time since 2006 at 17.9 percent as output from other sectors recovered from the downturn that ended in June 2009.
But even as recession-ravaged consumers avoided prescription drugs, hospitals, doctors and clinics in 2010, medical prices remained on an upward trajectory that slowed only marginally during the 2007-2009 recession.
It was not clear how consumers might have fared in 2011 as the recovery gathered pace and unemployment declined. But some analysts said the durability of healthcare prices and pent-up demand for services could suggest a sharp increase in costs down the road.
Federal spending for Medicare and Medicaid, which benefit the elderly and the poor, respectively, is also a key issue in partisan political wrangling in Congress over the mounting federal debt and deficit that is widely expected to gather momentum after the 2012 elections.
WHITE HOUSE CITES PREMIUM JUMP
The White House welcomed the report as evidence healthcare could be tamed but said it demonstrated the need for consumer protections set out in the Affordable Care Act health reform law, including a requirement that insurance companies justify large premium increases.
"In 2010, the net cost of health insurance - which includes the overhead and insurance company profits - increased by 8.4 percent. That's more than twice the increase in the cost of health care," deputy White House Chief of Staff Nancy-Ann DeParle said in an official blog posting.
Analysts also noted that insurance premiums grew faster than benefits for the first time in seven years.
The healthcare reform law, Obama's signature domestic policy achievement, accounted for only 0.1 percent of the rise in spending in 2010. But much of the law is not scheduled to take effect until 2014, when it is expected to extend coverage to more than 30 million uninsured Americans by expanding Medicaid and setting up state-run health insurance exchanges.
The federal government's $743 billion healthcare bill climbed to 29 percent of total spending, while other spending sources from businesses and households to state and local governments saw their shares of spending decline.
"The greater federal burden contributes more to the deficit, and so in early 2013 there will be even more pressure to cut back, specifically on Medicare, and the promises made to the uninsured through the Affordable Care Act," said Joseph Antos of the conservative American Enterprise Institute.
Federal spending in dollar terms rose mainly as a result of the Obama administration's efforts to help cash-strapped state governments by paying a greater share of Medicaid, which saw enrollment rise as 3.7 million people lost their private health insurance. The Medicaid assistance ended last July.
But the rate of spending growth slowed for both Medicaid and Medicare as Medicaid enrollment decelerated from recession levels and fewer senior citizens signed up for Medicare Advantage, which allows the elderly to purchase private insurance through Medicare.
Medicaid, which is jointly funded by federal and state governments, spent $401 billion, an increase of 7.2 percent. Medicare program costs grew 5 percent to $525 billion.
Prescription drugs, which accounted for 10 percent of healthcare spending, saw historically low growth due largely to the use of generic drugs, a drop in new product introductions and an increase in Medicaid prescription drug rebates.
Hospital services registered a fourth consecutive year of slower growth as consumers postponed medical care even at emergency rooms. Doctors and clinics also saw historically low spending growth, despite stable price increases, due to fewer visits and a less-severe flu season.
(Additional reporting by Anna Yukhananov)