Until recently, historical records on the social epidemiology of women’s health have been limited, and for the most part “gender-blind”. However, in 1999, a large-scale community based study, conducted by the Centre of Epidemiological Research in Southern Africa (CERSA) shed further light on the social and demographic characteristics of gender related health problems especially within the context of violence. (Jewkes et al, 1999) Their main findings were that:
- Emotional, psychological, financial and physical and sexual abuses are common features of most relationships.
- Physical violence often continues during pregnancy and constitutes and important cause of reproductive morbidity.
- Many women are injured by their partners, and considerable health sector resources are expended by providing treatment for these injuries.
- Injuries and diseases result in costs being incurred by other sectors, notably within the family, the community, employers and the national economy.
Psychological abuse also contributes to high levels of stress related illnesses such as emotional problems, which by far are the most debilitating (Adar & Stevens 2000:422). Often, the stress from physical abuse leads to so much psychological damage particularly when a woman is socially and physically isolated in poor rural communities and her ability to effectively care for herself and her children is often severely compromised. Unfortunately, many men are not conditioned to have healthy relationships and their solution to resolving their inner-conflicts is through anger and rage. By holding their partners responsible for their behaviour, men often accept no liability for their actions, regardless of the enormous psychological and physical trauma they inflict, even if their actions result in death (Jewkes 1999).
A 1999 study conducted by the Medical Research Council of South Africa revealed that almost 50% of men who were abused as children were at a higher risk of violent behaviour towards their partners (Abraham, Jewkes & Laubsher, 1999:5-7). Similarly, their research findings also found that health problems, specifically emotional and psychological, resulting from domestic violence were significantly more common among women who had experienced physical abuse during childhood while challenging traditional gender norms with more “liberal” ideas. Given the crucial importance of women within African society as mothers, nurturers, food producers, and income earners, their roles are understandably threatened by ill health. Also, with diminished socioeconomic status within the household, especially in rural communities, women are often forcibly isolated from their family and friends, which further restricts their ability to effectively retaliate, seek medical attention, or leave their abusive partners for fear of repeat victimization. Compared to their white counterparts, African women, especially in the poor rural areas, often have little or no access to healthcare facilities, and when their mental, psychological, or physical health is at risk this can pose an enormous problem.
It is important to understand that in South Africa’s highly stratified society there is an enormous bias towards high tech curative medicine. Within the more prosperous private sector, white patients receive five times as much funding as those in the public sector and less than 6 percent of state funding is targeted towards preventative medicine (Nagle, 1995:112) South Africa is also noted for its high technology, privately run Western-style medical healthcare system and services. Thus, the pattern of disease and mortality that has evolved shows that the more affluent whites experience relatively more degenerative diseases such as cancer, hypertension, cardio and cerebro-vascular diseases. Conversely, blacks and coloureds are more prone to infectious and contagious diseases along with stress related illnesses that are mainly the result of the lack of decent housing, adequate sewage disposal, clean running water, and generally unsanitary living conditions.
Poverty however, remains the primary cause of the prevalence of many diseases such as tuberculosis, cholera, and STDs. For women gender inequality and low social status conspires with poverty, which leads to a higher incidence of health related problems, and within the past decade HIV/AIDS. Children in particular are affected by diseases of malnutrition namely kwashiorkor and to a lesser extent, marasmus (Seedat, 1984:24). In South Africa, national wealth and income disparities are skewed in favour of the minority elite with the greatest majority of blacks living in poverty. On a macro level, these factors along with social development, lack of employment, population growth, and government allocations to healthcare have a direct bearing on health. Studies have shown that the shape of the HIV epidemic is determined by two key variables, one being the level of social cohesion and the overall levels of wealth and income distribution.
Low Socioeconomic status and gender inequality also threatens the health of adolescents, children and, most recently, infants in South Africa. Violence and promiscuous sexual activity, which can begin as early as fourteen, has led to a proliferation of teen pregnancies. According to the 2000 South African Health Review, “by the age of 19 years, 35% of all teenagers have been pregnant or had a child”. The socioeconomic and health impacts of teen pregnancies are also enormous. Although allowed by law to complete their schooling, pregnant teenagers are often denied the right to complete their education due to community control over schools. As a result, teen parenthood greatly reduces their educational achievements and future employment opportunities (Dickson-Tetteh & Ladha 2000). Most seriously, early sexual activity, especially in the absence of contraceptives and where rape is a factor, exposes adolescents to a heightened risk of contracting sexually transmitted diseases (STD’S), HIV and AIDS.
Another health impact on adolescents is Post Traumatic Stress Disorder (PTSD). The Unit on Anxiety Disorders at the MRCSA in Cape Town conducted a study on the stress related health effects of sexually based violence on adolescents who were exposed to events such as rape, gang violence or the witnessing of a family member being killed or assaulted. (Dickson et al, 2000). The study concluded that girls were two to six times more likely to develop PTSD than boys. Unfortunately, few children are able to obtain professional help, and if not treated within the first three months, the disorder becomes chronic and often leads to depression, and in women, suicide.
Poverty, low social status, inequality and violence have also had colossal impacts on the sexual and reproductive health status of African women. These health problems include sexually transmitted diseases (STDs) unsafe abortions, infertility, chronic pelvic disease, premature labour, perinatal and neonatal mortality, maternal mortality cervical cancer, and most importantly HIV/AIDS. Because of the extreme socioeconomic and racial divisions within the country, healthcare services for African women are grossly inadequate and unevenly distributed. For example, the majority of screening programs for cervical cancer are urban and targeted towards the more economically prominent whites. These groups have greater access to healthcare facilities, yet are at a lower risk of contracting the disease, which is more predominant among younger black women who engage in promiscuous sexual activities with older men (Wood & Jewkes 1996). For those in the poor rural areas without access to the free but unequally distributed provincial healthcare services late detection of the virus for effective treatment could cost a woman her life.
Today, the most serious geosocial impact of gender inequality, violence, and poverty is HIV/AIDS. The South African Government’s annual AIDS report, released in March 2002, indicated the crude rate of persons living with HIV had risen to approximately 6.5 million or 14.2% of the population. The province hardest hit has been KwaZulu Natal, with nearly 40% of the population infected, with substantially higher rates among younger women in the 15-24 age-group (Karim 2001). The report also indicated that over half a million predominately black South Africans had been infected with HIV alone. This represents a rate of 1,700 each day, and almost 60% of those bearing the brunt of this disease were adolescent girls and young women of prime childbearing age. One need not look far, whether historically or in other countries to appreciate that socioeconomic conditions especially related to gender inequality are crucial in determining exposure to disease. The AIDS Foundation of South Africa has identified some of the key dynamics within the context of social behaviour that have placed the country at a particularly higher risk of HIV.
- Social and family upheavals as a consequence of apartheid and years of migrant labour.
- High poverty and low education levels that contribute to riskier sex activities, especially among commercial sex workers.
- Presently high levels of STD’s
- The low status and vulnerability of women within society and their relationships, making it difficult for them to physically protect themselves from sex-related violence.
- Shifting social norms, which permit high number of sexual partners.
- A general cultural resistance to change high-risk sexual activities, especially within the context of contraception.
- Diminished and/or unequal access to health information and prevention.
- Many have fatalistic attitudes because of the harshness of the present; there is less concern about one’s health and the future.
Quite clearly, gender inequality, poverty, a woman’s vulnerability to violence, along with her inability to negotiate safe contraceptive measures, are critical factors behind these statistics, and the main reason why this disease is blazing out of control.
Poverty is considered to be the main determinant in the spreading of HIV among African women, and in South Africa, women represent the highest risk group. However, it is important to understand what poverty represents that is critical to understanding its influence on spreading the epidemic. The poor are often trapped in a cycle of poverty or “deprivation trap” and suffer the highest rate of disadvantage and marginalization (Farmer et al 1996). Within the poor household, families are generally large with little income to adequately provide for basic needs and lack of proper nutrition leads to poor school performance and lower labour output. In South Africa households that are hardest hit are in the rural areas or peripheral urban squatter settlements, which are isolated from social infrastructures such as schools, employment opportunities and healthcare facilities. (Seedat, 1984 and Lalthapersad-Pillay, 2003:41) These factors contribute to the vulnerability of the household unit and this is especially difficult when many women are excluded from the formal economy and forced into exploring other avenues within the informal sector in order to survive.
For desperate women, sex work, the definition of which can be complex, has become an economic necessity. Sex workers operate in a variety of settings from escort agencies to truck stops, and again black women are on the lowest rung of formal, albeit illegal, work sector (Abdool Karim and Frolich, 2000:76-77). A sex worker in the Kwa Zulu Natal area aptly captured and described the situation for many women: “A woman may go to look for employment all day and fail. On her way back home she might meet a man who wants to have sex with her. She will accept any amount of money in exchange for sex in order to purchase meals for her and her children. She could get AIDS from the person” (Abdool Karim and Morar, 1993). More recently, poverty has driven girls as young as 14 and 15 years into sex relationships with “sugar daddies”. Sex is frequently exchanged for gifts such as clothing, cell phones, school tuition and other favors and older men. The age difference between these young women with their older sex partners has dramatically increased their vulnerability to STDs, teen pregnancy, and HIV infection (Hunter, 2002). Today, it is virtually taken for granted that sexual relationships, which are never seen as prostitution, are cemented with gifts from men.
Fear of violence by known or unknown perpetrators in the commercial sex trade, has also facilitated viral transmission. Despite the knowledge that contraceptives will prevent the transmission of HIV/AIDS and other STDs, many men continue to be openly hostile towards the use of condoms even though consciously aware of these risks. In the case of sex workers these factors further contribute to their risk of infection, and if their partners do agree to contraceptive use, women are often forced to accept far less money in exchange for sex in order to purchase food for their families. Similarly, women within the informal urban economy experience health problems as a result of poverty and violence and are especially economically vulnerable because they lack access to the regulatory structures within the formal sector (Pick et al 2002). This “cycle of poverty” is therefore a strong determinant of the spread of HIV, and as a result, women have continued to suffer disadvantage and marginalization due to physical weakness, isolation, vulnerability to violence, and powerlessness.
Within the context of social epidemiology, mobility is a well-known determinant of epidemics, however, in South Africa the situation is particularly complex. Forced population resettlements under apartheid, continued migrant labour patterns due to industrial restructuring, major trade route movements especially among truckers, and refugees fleeing from other parts of war-torn Africa, have all contributed to the spread of infection (Laurie, 2000: 343-347). As previously discussed, women in poor rural areas, more particularly those in female-headed households, represent a high risk group, as they lack access to economic resources and due to the continuation of migrant labour patterns, most predominately in KwaZulu Natal, workers living near open-air brothers continue to participate in unprotected, promiscuous sexual activities, and later bring home the diseases, especially HIV, to re-infect their partners. These women are like “sitting ducks”, powerless to negotiate condom use and the ultimate victims of their partners’ risky behaviours (Abdool Karim & Frolich, 1999).
For biological reasons, women are also more vulnerable than men to the HIV/AIDS epidemic due to two main factors. During unprotected intercourse, whether through violence or consensual, a woman’s risk factor for being infected is 2-4 times higher than for men (Adar 2000). Females have a larger surface area of mucosa and when exposed to their partner’s secretions, which typically contain higher concentrations of the virus, their chances of becoming infected are greatly enhanced. Equally disturbing is that adolescents and younger women are at an even higher risk because of the immature cervix and scant vaginal secretions, which offer a less resistant barrier to HIV and STD’s, especially in the case of rape which results in mucosal lacerations due to tearing and bleeding.
Gendered inequality, violence and poverty have had far-reaching effects. Each year in South Africa, it is estimated that four million episodes of STDs occur, with over half among female adolescents and young women, many of whom are victims of violent crimes. According to South Africa’s Medical Research Council, in the November 2001 annual report: “by the time a South African women is 22 years old, there is a 24% chance that she has the HIV infection or AIDS”. In short, “her life is over, barely after she begins to enjoy adulthood and the prospects of marriage and children”. The report paints a further dismal scenario, by estimating that between five and seven million South Africans will die from AIDS in the next ten years with half of the deaths in the 15-49 year age-group, and women representing almost 60% of these deaths. Furthermore, mortality rates for women between 25-29 years are three times higher than a decade ago. In South Africa’s worst affected province, Kwa Zulu Natal, one in three women are currently infected, many of whom have been victims of violence.
The present and future impact of gender inequality that has lead to HIV/AIDS and other associated health problems has resulted in a “domino-effect” of colossal magnitude that will continue to affect all socioeconomic sectors of South African society. The most severe impact occurs at the household level when women become too ill to work and effectively care for themselves and their children. As previously discussed, poor households carry the greatest burden, with women experiencing the greatest impacts and the least resources available to cope. As the disease usually strikes more than one family member, the loss of income has a devastating financial impact. Household savings can be depleted as anti-retroviral drugs and other associated medications, until recently were not state-subsidized, nor paid for by private health insurers (Steinberg and Kinghorm 2000) With little or no regular household income there are increased medical and other associated costs which can occur simultaneously with family members reduced capacity to work and this can create a double economic burden. Economic hardships due to AIDS can diminish a mother’s ability to pay for her child’s education, food, and clothing, and often these children, especially girls, are expected to become the primary caregivers when one or more parent becomes permanently disabled.
The most tragic and enduring legacies of the AIDS epidemic are South Africa’s orphans, and caring for them is one of the greatest challenges facing the country today. Statistics vary as to the number of children who have lost their parents to AIDS, but according to the South African Health Review 2002, it was estimated that there were approximately 885,000 orphans under the age of fifteen, and by 2010 the number is expected to rise to just under two million of which almost 50% will be in the province of KwaZulu Natal (Steinberg and Kinghorm 2000). However, this reflects only a very small part of the far larger social tragedy. With a shortage of orphanages, many will grow up as street children or form child-headed households to avoid being separated from siblings. Along with the stigma attached to AIDS, the psychological and socioeconomic impacts are intense, and effective counseling, especially in rural areas is often unavailable or inaccessible. Orphans, especially girls will be more vulnerable to becoming HIV infected through continuing poverty, violence, sex work and emotional instability, leading to high-risk relationships which in turn further compromises their health status and perpetuates the epidemic. As children grow up in these pressurized environments, without adequate parenting, nurturing, support and future opportunities, they run the risk of developing antisocial traits, including violent behaviour. In short, should this vicious cycle continue, the socioeconomic consequences for children and society as a whole, will be profound.
Although colonial biomedicine did much to reduce the burden of infectious diseases, this also coincided with socioeconomic, development, and political changes, especially during apartheid. Today, African women continue to bear the brunt of poor health and any attempt to reduce their vulnerability must focus on structural changes, on issues relating to development, and on redressing the gender imbalance of power in society. Great strides have been taken by South Africa’s present government in designing policies aimed at improving the health status of women, however, progress has been slow and women continue to occupy the most vulnerable socioeconomic position within society. Gender-related violence, high unemployment, and continuing inequality continue to flourish, and the HIV/AIDS pandemic is no more than a new link in an old chain that has historically bound disease to poverty.
This refers mainly to black African women.
Today, this is known as the Poverty Datum Line (PDL)
Mager found that when conducting research on gendered relations and health in government archives, libraries, court documents, and manuscripts, feminist concerns were largely ignored as women were overlooked as historical subjects.
Most had lived in sub-economic and overcrowded living environments, exacerbated by alcohol and poverty, which contributed to conflict in the home. Also, these children were subject to severe discipline and punishment in the form of beatings, in which their fathers, stepfathers, or their mother’s boyfriends played a central role.
According to the South African Health Review 2001, given the country’s population of 44 million, there is an extreme maldistribution of psychiatrists that are qualified to treat mental disorders. Presently there are approximately 320 qualified practicing psychiatrists, a drop from 427 in 2000, of which 200 serve the wealthier private sector, thereby stretching the balance of only 120 to serve the state sector.
South Africa is well known for its pioneering techniques in open-heart surgery, and famous for the first human heart transplant on December 3, 1967 at Groote Schuur hospital.
This is often the result of peer pressure by their partners.
In South Africa, cervical cancer is the most common and accounts for approximately 30% of cancer deaths, of which coloured and black women figure predominately.
President Mbeki may have found more interesting alternatives to the explanations of the epidemic had a coherent social epidemiology of HIV been more prominent, rather than the dominant biomedical and behavioural approach.
This is also referred to as “transactional sex.