University of Zambia Medical Library

Volume 8 Number 1: January - March 2001

IN ASSOCIATION WITH:
THE MINISTRY OF HEALTH, ZAMBIA
THE DREYFUS HEALTH FOUNDATION OF NEW YORK
A GRANT FROM THE IBM CORPORATION

[ZHID Table of Contents]

EDITORIAL BOARD:
Dr. J.C. L. Mwansa, Microbiologist: University Teaching Hospital
Dr. Oliver Bowa, Surgical Anatomist: University of Zambia Surgery Department
Dr. Andrew Mbewe, Consultant Paediatrician: Kitwe Central Hospital
Ms. Nora Mweemba, Consultant-Information: World Health Organisation-Zambia
Mr. Sikwanda Makono, Specialist, Health Education, Ministry of Health
Ms. Christine Kanyengo, Medical Librarian (Acting): University of Zambia Medical Library

ADDRESS:
Zambia Health Information Digest
Medical Library
University of Zambia
School of Medicine
P.O. Box 50110
Lusaka, Zambia
Telephone: 260-1-250801
Fax: 260-1-250753
Email: medlib@unza.zm

Production of Zambia Health Information Digest is funded by the DREYFUS HEALTH FOUNDATION of New York under the Communication For Better Health ( CBH ) Programme.

TECHNICAL Production:
University of Zambia Medical Library

Project Coordinator:
Christine Kanyengo
Data Input:
Charity Kaulule
Circulations:
Kenneth Chanda
Lovelee Mwengwe
Sepiso Iliamupu
Philip Banda
Irene Nachilobe

ACKNOWLEDGEMENTS:
The Zambia Health Digest is produced to provide current information to health workers who have little access to current health related publications and information.

The abstracts of journal articles published in this quarterly Digest are obtained from the Medline database provided by the Dreyfus Health Foundation of New York. Abstracts are also selected from a database of Zambian health articles, which is continually being compiled at the UNZA Medical Library. Readers are encouraged to send in their work for inclusion in this Zambian health information database.

Computer equipment has been supplied through a grant from the IBM Corporation.

The Health Sciences Centre of the University of Florida, our cooperating partners, supply photocopies of the full text articles to the University Medical library on request, which in turn will be supplied to readers on request. When available in the library, articles will be photocopied at a nominal cost.

Production costs are supported by The Dreyfus Health Foundation of New York.

CUSTOM SEARCHES:
Using the MEDLINE compact disc databases, custom searches can be done on any health issue to obtain the most up-to-date information available. Readers are encouraged to submit requests for searches on relevant health problems which they face. Requests should be sent to the Medical Library, attention Christine Kanyengo

TABLE OF CONTENTS:

• Editorial
  
• Violence Against Women in Africa (Current Abstracts of Journal Articles - MEDLINE)
• Features:
  • AIDS: Men Make a Difference - Worlds AIDS Campaign
  • The Impact of Violence Against Women on Sexual and Reproductive Health
  • Recognising and Reducing Barriers to Cataract Surgery
  • Grain Found in the Eye
  • Death and the Second Sex
• Request Form for Full Length Text of Articles

A "life-cycle perspective" recognizes the specific kinds of violence suffered by girls and women at each stage of their life cycle, and their immediate and long-term effects. This throws the problem into high relief, presenting a compelling case for urgent public policy initiatives, particularly in the area of reproductive health.

Cataracts, often associated with aging (80%), are a major cause of blindness (more than 50% of cases of blindness in Africa), and for this reason, up to 80% of cases could be predicted or prevented Cataracts, often associated with aging (80%), are a major cause of blindness (more than 50% of cases of blindness in Africa), and for this reason, up to 80% of cases could be predicted or prevented (Auduge et al 1998). Although there are various foms of barriers to cataract surgery, it represents one way of solving the problem of cataracts amongst the population.

Thank you.

VIOLENCE AGAINST WOMEN IN AFRICA (Current Abstracts of Journal Articles -- MEDLINE)

This article explores the meaning of sexual rights as interpreted by different stakeholders during the development of the Beijing Programme of Action and within the Southern African Development Community (SADC). It illustrates how the lack of sexual rights as understood in the African context results from poverty as well as gender inequality, particularly in sexual relationships. This lack is manifested in the circumstances surrounding the HIV/AIDS pandemic and violence against women. In the European context, in contrast, sexual rights claims are motivated specifically in relation to sexual orientation. The article explores the extent to which these different discourses are being addressed in practice in SADC member countries and the opportunities that exist for building a concrete practice of sexual rights both in the region and internationally.

Partner notification of pregnant women infected with syphilis in Nairobi, Kenya..
Gichangi P, Fonck K, Sekande-Kigondu C, Ndinya-Achola J, Bwayo J, Kiragu D, Claeys P, Temmerman M
Int J STD AIDS 2000 Apr;11(4):257-61

We examined partner notification among syphilitic pregnant women in Nairobi. At delivery, 377 women were found to be rapid plasma reagin (RPR) reactive. Data were available for 94% of the partners of women who were tested during pregnancy; over 67% of the partners had received syphilis treatment while 23% had not sought treatment mainly because they felt healthy. Six per cent of the women had not informed their partners as they feared blame and/or violence. Adverse pregnancy outcome was related to lack of partner treatment during pregnancy (7% versus 19%, odds ratio (OR) 3.0, 95% confidence interval (CI) 0.9-10.0). Our data suggest that messages focusing on the health of the unborn child have a positive effect on partner notification and innovative and locally adapted strategies for partner notification need more attention.

Selling sex in the time of AIDS: the psycho-social context of condom use by sex workers on a Southern African mine.
Campbell, C
Soc Sci Med 2000 Feb;50(4):479-94

This paper provides a detailed account of the social organisation of commercial sex work in a squatter camp in a South African gold mining community. On the basis of in-depth interviews with 21 women, living in conditions of poverty and violence, the paper examines factors which might serve to help or hinder a newly implemented community-based peer education and condom distribution project aimed at vulnerable single women. Attention is given to the way in which the routine organisation of sex workers' everyday working and living conditions, as well as the strategies they use to construct positive social identities despite working in the most stigmatised of professions, serve to undermine their confidence in their ability to insist on condom use in sexual encounters with reluctant clients. However, even amongst this disadvantaged group of women, the interviews suggest that the tendency to speak of women's 'powerlessness' (as is the case in many studies of African women in the context of the HIV epidemic) is unduly simplistic and fails to take account of the range of coping strategies and social support networks that women have constructed to deal with their day to day life challenges. These strategies and networks could serve as potentially strong resources for community-based sexual health promotion programmes.

The intersections of HIV and violence: directions for future research and interventions.
Maman S, Campbell J, Sweat MD, Gielen AC
Soc Sci Med 2000 Feb;50(4):459-78

The purpose of this paper is to review the available literature on the intersections between HIV and violence and present an agenda for future research to guide policy and programs.

This paper aims to answer four questions: (1) How does forced sex affect women's risk for HIV infection? (2) How do violence and threats of violence affect women's ability to negotiate condom use? (3) Is the risk of violence greater for women living with HIV infection than for noninfected women? (4) What are the implications of the existing evidence for the direction of future research and interventions? Together this collection of 29 studies from the US and from sub-Saharan Africa provides evidence for several different links between the epidemics of HIV and violence. However, there are a number of methodological limitations that can be overcome with future studies.

First, additional prospective studies are needed to describe the ways which violence victimization may increase women's risk for HIV and how being HIV positive affects violence risk.

Future studies need to describe men'sperspective on both HIV risk and violence in order to develop effective interventions targeting men and women. The definitions and tools for measurement of concepts such as physical violence, forced sex, HIV risk, and serostatus disclosure need to be harmonized in the future. Finally, combining qualitative and quantitative research methods will help to describe the context and scope of the problem.

The service implications of these studies are significant. HIV counseling and testing programs offer a unique opportunity to identify and assist women at risk for violence and to identify women who may be at high risk for HIV as a result of their history of assault. In addition, violence prevention programs, in settings where such programs exist, also offer opportunities to counsel women about their risks for sexually transmitted diseases and HIV.

Postcoital injuries treated at the Addis Ababa Fistula Hospital, 1991-97.
Muleta M, Williams G
Lancet 1999 Dec 11;354(9195):2051-2

91 young Ethiopian women who had developed total faecal incontinence frominjuries sustained from sexual intercourse within marriage or rape weresuccessfully treated at this hospital. No abstract supplied by MEDLINE

Recent medical evidence for torture and human rights abuse in Sierra Leone: a report for the Medical Foundation for the Care of Victims of Torture.
Lawson, M
Med Confl Surviv 1999 Jul-Sep;15(3):255-70

A study was carried out using the case notes of all Sierra Leoneans referred to the Medical Foundation for the Care of Victims of Torture between 1996 and 1998 for medical reports. Data were abstracted on the type and extent of torture reported, and the cases were followed up to the present day to ascertain how long the United Kingdom asylum and immigration process had taken to process their claims. In the sample of 36 cases there were 68 reported incidents of torture or human rights abuse. Sixty-nine per cent (18/26) of the women in the sample had been raped at least once, and 72% (26/36) of the sample had been beaten at least once. The average time for the minimum due process of the asylum claim to be processed was 44 months (3.7 years). On 31 January 1999, 61% of the sample (22 people) were still involved in the asylum process. Waiting times must be reduced and safeguards imposed so that those who have suffered torture can be rapidly identified and referred for medical treatment, care and documentation.

HIV/STD: the women to blame? Knowledge and attitudes among STD clinic attendees in the second decade of HIV/AIDS.
Rakwar J, Kidula N, Fonck K, Kirui P, Ndinya-Achola J, Temmerman M
Int J STD AIDS 1999 Aug;10(8):543-7

We aimed to determine the knowledge and attitudes towards HIV/STDs among women attending an STD clinic by interviewing 520 randomly selected women. Nearly all had heard of HIV/AIDS/STDs, with posters, pamphlets and the radio being the main source of their information. The years of schooling was the only predictive factor of knowing a preventive measure of HIV. Two-thirds thought they were at risk of contracting HIV from their regular partner. Knowledge of the sexual habits of their male partners was low with 260 (50%) of the women distrusting their partner. Only 52 (10%) of respondents admitted to sex in exchange for gifts or money. In the event of a positive HIV test result, the perceived partner response would be to blame the woman for introducing the infection into the relationship. After a positive HIV test result, only 3.5% would resort to using condoms while another 3.7% would try to pass on the disease to other people.

The quality of their knowledge of the transmission of HIV was low in spite of the fact that most respondents have heard of HIV/AIDS/STDs. Violence against women was expected in relation to a positive test result. There is a need for better educative effort on the modes of transmission and prevention of HIV, also in 'low risk' populations.

Advocacy for gender equity: the case of bridewealth in Uganda.
Promot Educ 1999 Jun;6(2):13-5, 37-8, 49
Davies, C

No abstract supplied by MEDLINE

Reversal in mortality trends: evidence from the Agincourt field site, South Africa, 1992-1995.
Tollman SM, Kahn K, Garenne M, Gear JS
AIDS 1999 Jun 18;13(9):1091-7

• OBJECTIVE:
  To examine changes in mortality in rural South Africa over the period 1992-1995 by age, sex and cause of death. DESIGN: As with much of sub-Saharan Africa, South Africa lacks effective vital registration and information on mortality is lacking. The Agincourt demographic and health surveillance system was established to inform health policy and practice with regard to rural subdistrict populations.
• METHODS:
  Prospective community-based study involving annual update of a household census with enquiry into all birth, death and migration events. All reported deaths (n = 1001) are the subject of a verbal autopsy.
• RESULTS:
  An increasing trend in overall mortality relative to general population growth in the study area is apparent. There is evidence for a reversal in the previously declining trend in mortality among women 20-44 years. A comparison of 1992-1993 with 1994-1995 shows that most of the increase in mortality is concentrated in the younger adult (20-49 year) age group. AIDS and related diseases, particularly tuberculosis, appear primarily responsible. Injuries and violence (especially homicide) and circulatory disease are important, under-recognized causes of death, although their levels have remained constant over the period.
• CONCLUSIONS:
  Mortality from AIDS and related diseases appears responsible for the probable reversal in mortality emerging in South Africa's rural northeast. Findings carry implications for the emerging system of decentralized health care.

Couple communication, sexual coercion and HIV risk reduction in Kigali, Rwanda.
van-der-Straten, A; King, R; Grinstead, O; Serufilira, A; Allen, S
AIDS. 1995 Aug; 9(8): 935-44

• OBJECTIVE:
  To describe sexual interaction and HIV-related communication in Rwandan couples and to examine their relationship to HIV testing and condom use.
• STUDY DESIGN:
  Cross-sectional survey of a longitudinal cohort.
• METHODS:
  In 1988, women recruited for an epidemiological study of HIV, and interested male partners, received confidential HIV testing and counseling. Two years after enrollment, 876 women reporting one steady partner in the past year completed a questionnaire addressing sexual and HIV-related communication, sexual motivation and violence in the partnership.
• RESULTS:
  Men control sexual decision making, and coercive sex and violence between partners is not uncommon. HIV-positive women were more likely to report coercive sex and less likely to have discussed their test results with their partner. Women with HIV-positive partners were more likely to report being physically abused. Condom use was more common if the man had been previously tested, and if women r! eported discussing or negotiating condom use. HIV-negative women with untested or seronegative partners were the least likely to use condoms or to discuss or attempt to negotiate condom use.
• CONCLUSIONS:
  Participation of the male partner is crucial for successful HIV risk reduction in couples. HIV testing and counseling of couples has beneficial long term effects on condom use and HIV-related communication. Couple communication is associated with condom use, but only when the discussion is specific (sexually transmitted disease risks and using condoms). Seronegative women with untested partners are at increased risk for HIV as they are the least likely to discuss or attempt to negotiate condom use.

Jaw fractures in Enugu, Nigeria, 1985-95.
Oji, C
Br J Oral Maxillofac Surg 1999 Apr;37(2):106-9

A retrospective analysis of 900 patients with jaw fractures of the facial bones during the period January 1985 - December 1995 indicated that 747(83%) resulted from road traffic accidents, 75(8.4%) from interpersonal violence, 39(4.3%) from accidents during sporting events, and 36(4%) from occupational accidents, while the causes of 3(0.3%) were not stated. The left side of the face was affected more often than the right. The mandible was twice as likely to be fractured as the zygomaticomaxillary complex. The symphysis-body-angle and the condylar region were the most common sites of fracture of the mandible, while the zygoma was the area most often affected in the middle third of the face.

Mostmaxillofacial fractures occurred in the age group 21-30 years, and the lowest among those over 60. Three times as many men were affected as women. We conclude that there is high incidence of fractures of the facial bones caused by traffic accidents in our environment and, in all age groups, men were more likely to be affected than women.

Magnitude, type and outcomes of physical violence against married women in Butajira, southern Ethiopia.
Deyessa N, Kassaye M, Demeke B, Taffa N
Health Policy Plan 1998 Dec;13(4):459-64

no abstract supplied by MEDLINE

The impact of epilepsy on the quality of life of people with epilepsy in Zimbabwe: a pilot studyMielke J, Sebit M, Adamolekun B
Ethiop Med J 1998 Apr;36(2):83-92

The seriousness in magnitude of physical violence globally, and lack of information on the dimensions and context of the problem in Ethiopia is very visible. A cross-sectional survey was conducted in Meskanena Mareko Woreda, Southern Ethiopia, from November 1 to 30, 1995 to assess the magnitude, type and outcomes of physical violence against married women. A total of 673 married women were included in the study. The study found out the overall prevalence of physical violence against married women to be 45% and 10% in their lifetime and last three months, respectively. Two hundred and twenty nine (76%) and 39 (60%) of the lifetime and three month's physically abused women respectively, were slapped with fist. Four (1%) of the lifetime physically abused women have been abused using a knife or a gun. Among the 303 physically abused women, 161 (53%) reported minor and serious somatic injuries in their lifetime. One hundred and nine (46%) of them had acquired minor lacerations or scars; 22 (7%) had reported to have fracture or dislocation; and 5 (2%) had lost their vision. It is concluded that physical violence among married women is quite high and a serious problem. We recommended that policy makers need to urgently explore for appropriate strategies to curtail the problem of physical violence against married women.

Ethnicity and sexual behavior in Ghana.
Addai I
Soc Biol 1999 Spring-Summer;46(1-2):17-32

Using data from the 1993 Ghana Demographic and Health Survey, this study explores the relationship between ethnicity and sexual behavior: having sex before age 17 and premarital sexual experience. All ethnic groups show substantial sexual experience before age 17 and premarital sexual engagement. Logistic regression analyses reveal that in general ethnicity influences the behaviors studied, especially for ever-married women. The data suggest that groups that practice matrilineal and patrilineal systems show differences in the likelihood of having sex before age 17. Contrary to expectation, there is an inverse relationship between education and sexual experience before age 17. The findings highlight the importance of group-specific programs in Africa.

Violence against women in Sierra Leone: frequency and correlates of intimate partner violence and forced sexual intercourse.
Coker AL, Richter DL
Afr J Reprod Health 1998 Apr;2(1):61-72

Violence against women is a significant public health problem which impacts women, men, and children. Little is known about the frequency or correlates of violence against women in Africa. In this cross-sectional study, we found that 66.7% of 144 women surveyed in a study of AIDS knowledge, attitude, and behaviours, report being beaten by an intimate male partner and 50.7% report having ever been forced to have sexual intercourse; 76.6% of women report either forced sex or intimate partner violence. Circumcised women were most likely to report intimate partner violence and forced sexual intercourse. To improve the health of women worldwide, violence against women must be addressed.

Sexual abuse in children in Cameroon.[Article in French]
Menick DM, Ngoh F
Med Trop (Mars) 1998;58(3):249-52

The purpose of this study was to determine the incidence and socio-demographic features of child sexual abuse in an African setting. The files of 5082 children seen between August 1, 1992 and July 31, 1997 at the Center for Mother and Child Protection in Yaounde, Cameroon, were retrospectively reviewed. Sexual abuse was recognized in a cohort of 104 children of both sexes. The incidence of sexual abuse in the studied population was 2.05%. The victims were more often girls than boys: 95.2% vs 4.8%. Assault usually occurred during prepuberty (41.4%) and puberty (20.2%). However a non-negligible number of cases, all involving girls, occurred before the age of 10 years (29.8%). Assaults by women occurred but were uncommon (7.8%). Rape was the most frequent form of abuse (97.1%). About 25% of cases occurred within the family. These findings confirm the existence and incidence of child sexual abuse in an African setting and raise the taboo on the absolute phallocratic power of fathers and uncles over young girls and women in general. This study also provides new evidence of the vulnerability of women in Africa as a result of their traditional status in society.

Stories of growing up amid violence by refugee children of war and children of battered women living in Canada.
Berman H
Image J Nurs Sch 1999;31(1):57-63

• PURPOSE:
  To explore how two groups of children who grew up amid violence "make sense" of their experience. As violence has become a common element of some societies, growing numbers of children have been forced to live in dangerous environments. Although considerable research has been conducted with children who are abused or neglected, the needs of those who witness violence have been largely overlooked.
• DESIGN:
  Critical narrative and descriptive. Data were collected, 1995-1996, in Canada from a convenience sample of 16 refugee children of war and 16 children of battered women.
• METHODS:
  Participants were asked open-ended questions about the violence in their lives, their feelings about what occurred, their thoughts about the reasons for violence, and their ways of surviving and growing. Common themes were identified and validated.
• FINDINGS:
  Despite differences in the children's stories, many parallels were evident. Both groups of youngsters endured pain, suffering, and feelings of betrayal. Both used creative strategies to survive. The way the children endured growing up amid violence was mediated by social, political, and cultural constructions of violence. Because these meanings were unique, violence was experienced in several ways.
• CONCLUSIONS:
  Although the children showed remarkable strength and insight, they face many challenges. Despite a common perception that children are unable to talk about deeply troubling experiences, this research demonstrated that children not only want to discuss their experience, but also welcome the opportunity to do so.

Paediatric AIDS in Jos, Nigeria.
Angyo IA, Okpeh ES, Onah J
West Afr J Med 1998 Oct-Dec;17(4):268-72

A retrospective study of all children admitted with the diagnosis of acquired immunodeficiency yndrome (AIDS) at Jos University Teaching Hospital (JUTH) between August 1995 and October 1996 was carried out. Forty three (1.5% out of a total of 2793 children were diagnosed with HIV infection during the study period. However, only the records of 23 out. Of the 43 positive cases were available for analysis. Of the 23 cases whose records were available, 8 presented in 1995, while the remaining 15 presented between January and October 1996. The ages of the children ranged between 1 and 15 years (Mean 3.0 +/- 4.1 Years). There were 12 males and 11 females (M:F = 1:1). Sixteen (69.6 percent) out of the 23 patients were aged between 1 month and 2 years. Sixteen (69.6%) of the 23 patients acquired the infection vertically, 2 (8.9%) acquired the infection through blood transfusion, 1 (4.3%) from sexual abuse, while in 4 (17.4%) the source of infection could not be established due to inadequate data. Majority of the children presented with weight loss, chronic diarrhoea and fever, while the common findings included wasting, oralthrush, pallor, hepatosplenomegaly and lymphadenopathy. Six (26.1 percent) out of the 23 children died, 8 (34.8 percent) were discharged against medical advice and have not been seen since, 9 (39.1%) improved and were discharged to out-patient clinic followup, but all except 2 of these have been lost to follow-up. It is concluded that AIDS is increasingly becoming a major cause of childhood morbidity and mortality in our environment. All children in our environment who present with features of malnutrition should be screened for AIDS. Campaigns aimed at preventing vertical (maternal-child) transmission, including health education of young men and women on the risk of unprotected sex must be vigorously pursued and sustained.

Emergency contraception among refugees and the displaced.
Goodyear L, McGinn T
J Am Med Womens Assoc 1998;53(5 Suppl 2):266-70

In 1994, the international relief community began to recognize and address the reproductive health needs of refugees and displaced populations. A minimum initial service package of reproductive health services for refugees and the displaced, which includes emergency contraception (EC), was developed and recommended for use in refugee settings. This paper describes the experience of one international relief organization, the International Rescue Committee (IRC), in introducing EC into its worldwide reproductive health program. A recent IRC survey found that EC is available in 4 out of 14 settings where it provides reproductive health services. A case study from Tanzania demonstrates the modes of delivery, the demand for EC by women who have experienced sexual violence, and the community responses to this method of contraception. More information, education, and communication directed at refugee communities; more donor support for supplies; and institutional commitment to train staff are needed to expand refugee access to EC.

"He forced me to love him": putting violence on adolescent sexual health agendas.
Wood K, Maforah F, Jewkes R
Soc Sci Med 1998 Jul;47(2):233-42

Violence against women within sexual relationships is a neglected area in public health despite the fact that, in partially defining women's capacity to protect themselves against STDs, pregnancy and unwanted sexual intercourse, it directly affects female reproductive health. This paper presents the findings of a qualitative study conducted among Xhosa-speaking adolescent women in South Africa which revealed male violent and coercive practices to dominate their sexual relationships. Conditions and timing of sex were defined by their male partners through the use of violence and through the circulation of certain constructions of love, intercourse and entitlement to which the teenage girls were expected to submit. The legitimacy of these coercive sexual experiences was reinforced by female peers who indicated that silence and submission was the appropriate response. Being beaten was such a common experience that some peers were said to perceive it to be an expression of love. Informants indicated that they did not terminate the relationships for several reasons: beyond peer pressure and the probability of being subjected to added abuse for trying to end a relationship, teenagers said that they perceived that their partners loved them because they gave them gifts of clothing and money. The authors argue that violence has been particularly neglected in adolescent sexuality arenas, and propose new avenues for sexuality research which could inform the development of much-needed adolescent sexual health interventions.

Reports of husband battering from an undergraduate sample in Umtata.
Mwamwenda TS
Psychol Rep 1998 Apr;82(2):517-8

The objective of the present study was to explore the extent to which husband battering is practised among Xhosa-speaking women (n = 138) and men (n = 81) in Transkei. Analysis showed that husband battering is not an unknown sociological practice as a small number of women do in fact beat up their husbands. Contrary to conventional and cultural knowledge wife battering is not a one-way phenomenon although it is practised more widely.

Current status of the female condom in Africa. [Article in French]
Deniaud F
Sante 1997 Nov-Dec;7(6):405-15

The female condom was developed in the 1980s. It is a contraceptive device used by women that protects against both pregnancy and sexually-transmitted diseases (STDs) including HIV infection. Two studies have investigated the contraceptive effectiveness of the female condom, and it was found to be as effective as other barrier methods. It has been shown to be effective against STD and HIV transmission in vitro but there is only limited evidence of its efficacy in vivo. No serious local side effects or allergies have been reported and the female condom can be used with any type of lubricant, spermicidal cream or foam.

The female condom is the only device other than the male condom that has been shown to prevent HIV transmission. The female condom has been marketed in 13 countries since the summer of 1996. Most of these countries are industrialized and the selling price in these countries is too high for developing countries.

Sub-Saharan Africa has very high prevalence rates for HIV infection, at least 30% of the general population in Eastern and Central regions. The epidemic is also spreading fast in some parts of the Western region. In Ivory Coast for example, 12 to 15% of pregnant women are infected. African women are subordinate to men in many aspects of their lives, politically, educationally, socially and sexually. This sexual inequality makes them highly vulnerable to STDs, including HIV, and unwanted pregnancies. This paper reviews 10 of the 15 studies carried out in sub-Saharan African countries between 1990 and 1996 and compiled by the World Health Organization. Recruitment methods, education of subjects, methodology and assessment of acceptability differed between studies.

Despite these limitations, most studies concluded that the women who participated in the trials generally found the female condom acceptable. Acceptability was established quicker among prostitutes than among other women and men found the female condom less acceptable than did women. However, the sample size is too small to draw any firm conclusions. Commercial sex workers in the studies reviewed were very interested in this new method because it gave them an additional method of safer protection during sex. However, they were occasionally faced with difficult negotiations with some clients, refusal to use the female condom and sexual violence. Reuse of the device was reported in four studies, but the term reuse is seldom defined. In cases where it was defined, the frequency of reuse, with washing of the device, accounted for no more than 1% of the total number of uses. The acceptability of the female condom among women other than prostitutes faces two obstacles, the reaction of the woman's regular partner and attitudes to the device itself (appearance, difficulties or uneasiness concerning its use). However, some women liked it because it provided dual protection against pregnancy and STDs and sexual pleasure. The moderate level of acceptability to male partners may be overestimated because women whose partners disliked the device would be more likely to discontinue its use. The studies of acceptability reviewed here show that use of the female condom in Africa is realistic and that it provides women with more independent protection.

Initial negative perceptions of the device are often replaced with a more positive reaction after several uses. The experience gained with use reduces the technical problems. We need to overcome the stereotypes, simplifications and strong opinions that threaten to damage the acceptance of this new method and efforts to encourage women to adopt it. However, we still require further clinical data on the effectiveness of the female condom at preventing pregnancy and HIV transmission. Availability of the female condom is improving in Africa.

Pilot marketing studies were launched in 1996 in Guinea, Zambia, South Africa, followed by Uganda and Tanzania. There are local initiatives in Ivory Coast and Zimbabwe.

Violence against women during the Liberian civil conflict.
Swiss S, Jennings PJ, Aryee GV, Brown GH, Jappah-Samukai RM, Kamara MS, Schaack RD, Turay-Kanneh RS
JAMA 1998 Feb 25;279(8):625-9

• CONTEXT:
  Civilians were often the casualties of fighting during the recent Liberian civil conflict. Liberian health care workers played a crucial role in documenting violence against women by soldiers and fighters during the war.
• OBJECTIVE:
  To document women's experiences of violence, including rape and sexual coercion, from a soldier or fighter during 5 years of the Liberian civil war from 1989 through 1994. DESIGN: Interview and survey.
• SETTING:
  High schools, markets, displaced persons camps, and urban communities in Monrovia, Liberia, in 1994.
• PARTICIPANTS:
  A random sample of 205 women and girls between the ages of 15 and 70 years (88% participation rate).
• RESULTS:
  One hundred (49%) of 205 participants reported experiencing at least 1 act of physical or sexual violence by a soldier or fighter. Survey participants reported being beaten, tied up, or detained in a room under armed guard (17%); strip-searched 1 or more times (32%); and raped, subjected to attempted rape, or sexually coerced (15%). Women who were accused of belonging to a particular ethnic group or fighting faction or who were forced to cook for a soldier or fighter were at increased risk for physical and sexual violence. Of the 106 women and girls accused of belonging to an ethnic group or faction, 65 (61%) reported that they were beaten, locked up, strip-searched, or subjected to attempted rape, compared with 27 (27%) of the 99 women who were not accused (P< or =.02, .07, .001, and .06, respectively). Women and girls who were forced to cook for a soldier or fighter were more likely to report experiencing rape, attempted rape, or sexual coercion than those who were not forced to cook (55% vs 10%; P< or =.001, .06, and .001, respectively). Young women (those younger than 25 years) were more likely than women 25 years or older to report experiencing attempted rape and sexual coercion (18% vs 4%, P=.02 and .04, respectively).
• CONCLUSIONS:
  This collaborative research allowed Liberian women to document wartime violence against women in their own communities and to develop a unique program to address violence against women in Liberia.

The effect of women's role on health: the paradox.
Kabira WM, Gachukia EW, Matiangi FO
Int J Gynaecol Obstet 1997 Jul;58(1):23-34

Most societies in Africa are patriarchal in nature. Traditional Africa has allocated the role of nurturing, and ensuring the health of the family and the community as a whole to women. From the age of six, girls begin to work with their mothers, cleaning, sweeping, nursing and caring for the younger children, the aged and the sick. Therefore, the female child is customarily socialized as the custodian of family health. Because women are traditionally responsible for health in African countries and their status in society is low, the status of the health sector has received less attention than other sectors. The paradox of entrusting the woman with the responsibility of health and at the same time denying her the opportunities to influence policies remains a major obstacle.

Factors that influence women's health in Africa most commonly include poverty, poor education and poor nutrition. Access to education for African women is a major problem. The impact of a poorly educated mother is passed on to the daughter. In some parts of Africa, female circumcision contributes to the high school dropout rates. Once the girls are withdrawn from school to participate in the ceremonies, they do not return to school. They are encouraged and socialized towards marriage. Africa has the highest fertility rate, the lowest life expectancy (49 years for males and 52 for females, the highest infant mortality rate (114 deaths per 1000 live births); the highest maternal mortality rate and the highest dependency ratio (47% under 15 years and only 3% over 65). The foregoing factors call for urgent attention to health issues, especially those which affect women who are the traditional health providers.

There is an unacceptably high rate of unsafe abortion which accounts for up to 30% of maternal mortality in some African countries, and there is growing concern over teenage pregnancies in some African countries. Nearly two-thirds of the cases of septic abortions are in the 15-19-year age group and yet African governments and the legal systems would rather not deal with abortion. The gap between mortality and fertility is widening; it doubled between 1972 and 1994 and is expected to double in 2017. In many African countries, children are the only 'goods' that women are expected to produce. Unless this attitude changes, fertility rates will continue to rise as women continue to search for their place in society and justify their place within marriages and relationships through child bearing.

Epidemiological portrait of acquired immunodeficiency syndrome and its implications in Benin. [Article in French]
Fourn L, Ducic S
Sante 1996 Nov-Dec;6(6):371-6

The HIV/AIDS threat continues in African countries, including the Republic of Benin, during this period of economic crisis which is accentuated by the devaluation of the currency. National statistics from the Ministry of Health indicate a progression of the number of cases seropositive for HIV and the number of cases developing AIDS. Concomitantly, we observe a decrease of the number of teenagers fearing HIV infection and a spread or risky sexual behavior, such as unprotected sex. Despite the weak prevalence of HIV infection in Benin, the increase of the number of cases with AIDS remains a serious social problem.

This paper describes the epidemiological pattern of AIDS and its social, demographic and economical implications as they affect the current national program to increase the awareness of the problem. We obtained scientific information on the epidemiological chain of AIDS morbidity from prior research results, data from the disease control centers and interviews with the parents of some patients. Quantitative data was collected from twenty selected disease control centers of the national program against AIDS from 1986 to 1995. We compared these data with data obtained by the WHO from 1986 to 1992 from the neighboring countries of Benin. We observed an exponential growth of the cumulative number of AIDS cases, from one declared case in 1985 to 1,280 cases in 1995, including twenty thousand cases seropositive for HIV in 1991. The majority of cases were people between 20 and 49 years old and were predominantly males.

Heterosexual (73%), homosexual (0.8%), and mother to child vertical transmission were the principal modes of transmission registered for carriers of HIV-1, HIV-2, or both. The qualitative study revealed a social situation dominated by verbal violence against infected women, absenteeism at work of the patients' family and, friends and a psychological impact on the children of the patients.

An evaluation of the direct costs of AIDS was estimated to be $217,600 (US $) for the 1,280 reported cases. We suggest further reinforcement of the program to raise the awareness of the young people in the urban and rural areas of the country.

Urban violence and health--South Africa 1995.
Gilbert L
Soc Sci Med 1996 Sep;43(5):873-86

Many cities all over the world are the loci of various forms of violence. Violence is a complex phenomenon, its causes are multidimensional and its consequences have ramifications far beyond the immediate perpetrators and victims. The aim of this paper is to review various forms of urban violence and their health consequences, locating them in the wider South African context.

Owing to the lack of centralised data, the information presented in this paper is based on the best available data derived from numerous sources. Using the socio-environmental model of health and disease as a framework, violence and its impact on health is discussed. The brief review of political violence, violent crimes, violence against women and domestic violence in South Africa, highlights the fact that SA is a particularly violent society. The data presented suggest a link between the social context of violence and its health consequences, dealing with the impact of urban violence in the form of physical trauma as well as emotional trauma associated with it. Consequently, adopting a comprehensive approach, that violence needs to be understood in the wider societal context and has to be dealt with in the broadest terms possible, as advocated by the "New Public Health" approach, a way forward to reduce levels of violence and cope with its health consequences is suggested. An emphasis is placed on the three levels of prevention and the vital collaboration between the judicial system, police, the health sector as well as the community.

Reproductive and sexual health: a research and developmental challenge.
Mbizvo, MT
Cent Afr J Med 1996 Mar;42(3):80-5

There is a growing awareness of the burden and implications of reproductive ill health as contributed by unsafe motherhood (during pregnancy, childbirth, abortion), reproductive tract infection (RTIs) and cancer, sexually transmitted infections (STIs) including the human immunodeficiency virus (HIV), poorly regulated fertility, infertility, unwanted pregnancy and adolescent/teenage sexuality and pregnancy. Sexual health further entails a state of well-being in expression of sexuality, prevention of unwanted pregnancies, prevention of STIs and AIDS and freedom from sexual abuse and violence.

Reproductive health is increasingly being recognized as one of the corner stones of health and a major determinant and indicator of human social development. It is central to general health as it reflects health in childhood and adolescence and sets the stage for health and life expectancy beyond the reproductive years. It is affected by other health aspects such as nutrition and environment, low birth weight, neonatal and perinatal mortality and morbidity. According to the WHO, reproductive health problems account for more than one third of the total burden of disease in women and more than 10 pc of that in men. The challenges posed by the subordinate status of women, the exclusion of men in reproductive health programmes and the need for shaping adolescents' sexual knowledge and behaviour are viewed against today's poor reproductive and sexual health outcomes in the context of Africa. Education systems, employers and policy makers are challenged to provide adequate STI/HIV education and on-site (school, work, satellite, drop in) control services. Prevention interventions, disease and health trends and their outcome require systematic research in order to impact on policy.

Reproductive health education should be universal, especially for adolescents, and its impact assessed against appropriate monitoring criteria such as reproductive morbidity, STI prevalence and abortion complications.

Effects on asylum seekers of ill treatment in Zaire.
BMJ 1996 Feb 3;312(7026):293-4
Peel, MR

To describe the health effects of the political system in Zaire on asylum seekers seen at the Medical Foundation for the Care of Victims of Torture a retrospective study was performed of the records of 92 asylum seekers from Zaire who were seen for medical reports at the medical foundation in 1993 and 1994.

Eighty one had been imprisoned; the others had been severely treated at home by the security services. Sixty six had been detained for up to one year. Prison conditions were invariably unsanitary, and food of poor quality when provided. All had been beaten on arrest, and all but two had been beaten repeatedly in prison. Nearly all the women and some of the men described sexual abuse. Almost all left prison through bribery or because a guard had a similar background. Seventy two asylum seekers had scarring, consider to be consistent with the history, and 70 were considered to have suffered persistent psychological damage. Asylum seekers from Zaire will have health effects from experiences unimaginable to the ordinary Briton. An understanding of the background will help clinicians manage them.

The politics of women's health: setting a global agenda.Int J Health Serv 1996; 26(1):47-65
Doyal, L

The last decade has been marked by a rapid growth in the women's health movement around the world. There has been a marked shift in activities away from the developed countries, as campaigns increase in intensity in Africa, Asia, and Latin America. The practice of women's health politics has also become increasingly international with sustained and effective collaboration across the north-south divide. Both the goals of these campaigns and their methods vary with the circumstances of the women involved. But despite this diversity, common themes can be identified: reproductive self-determination; affordable, effective, and humane medical care; satisfaction of basic needs; a safe workplace; and freedom from violence.

Reducing the risk of HIV infection among South African sex workers: socioeconomic and gender barriers.
Karim QA, Karim SS, Soldan K, Zondi M
Am J Public Health 1995 Nov;85(11):1521-5

• OBJECTIVES.
  The social context within which women engaged in sex work at a popular truck stop in South Africa are placed at risk of human immunodeficiency virus (HIV) infection and the factors that influence their ability to reduce their risk were assessed.
• METHODS.
  Using qualitative and quantitative techniques, an elected sex worker from within the group collected all data.
• RESULTS.
  Given the various pressing needs for basic survival, the risk of HIV infection is viewed as one more burden imposed on these women by their lack ofsocial, legal, and economic power. Violence, or the threat thereof, plays an important role in their disempowerment. In the few instances in which sexworkers were able to insist on condom use, it resulted in a decrease inearnings, loss of clients, and physical abuse.
• CONCLUSIONS.
  Recommendations to reduce the sex workers' risk for HIV infection include negotiation and communication skills to enable them to persuade their clients to use condoms; development of strategies through which they can maximally use their groupstrength to facilitate unified action; and accessibility of protective methods they can use and control, such as intravaginal microbicides.

Community-perceived benefits of ivermectin treatment in northeastern Nigeria.
van der Straten A, King R, Grinstead O, Serufilira A, Allen S
AIDS 1995 Aug;9(8):935-44

• OBJECTIVE:
  To describe sexual interaction and HIV-related communication in Rwandan couples and to examine their relationship to HIV testing and condom use. STUDY DESIGN: Cross-sectional survey of a longitudinal cohort.
• METHODS:
  In 1988, women recruited for an epidemiological study of HIV, and interested male partners, received confidential HIV testing and counseling. Two years after enrollment, 876 women reporting one steady partner in the past year completed a questionnaire addressing sexual and HIV-related communication, sexual motivation and violence in the partnership.
• RESULTS:
  Men control sexual decision making, and coercive sex and violence between partners is not uncommon. HIV-positive women were more likely to report coercive sex and less likely to have discussed their test results with their partner. Women with HIV-positive partners were more likely to report being physically abused. Condom use was more common if the man had been previously tested, and if women reported discussing or negotiating condom use. HIV-negative women with untested or seronegative partners were the least likely to use condoms or to discuss or attempt to negotiate condom use.
• CONCLUSIONS:
  Participation of the male partner is crucial for successful HIV risk reduction in couples. HIV testing and counseling of couples has beneficial long term effects on condom use and HIV-related communication. Couple communication is associated with condom use, but only when the discussion is specific (sexually transmitted disease risks and using condoms). Seronegative women with untested partners are at increased risk for HIV as they are the least likely to discuss or attempt to negotiate condom use.

The right not to know HIV-test results.
Temmerman M, Ndinya-Achola J, Ambani J, Piot P
Lancet 1995 Apr 15;345(8955):969-70

Large numbers of pregnant women in Africa have been invited to participate in studies on HIV infection. Study protocols adhere to guidelines on voluntary participation after pre-test and post-test counselling and informed consent; nevertheless, women may consent because they have been asked to do so without fully understanding the implications of being tested for HIV. Our studies in Nairobi, Kenya, show that most women tested after giving informed consent did not actively request their results, less than one third informed their partner, and violence against women because of a positive HIV-antibody test was common. It is important to have carefully designed protocols weighing the benefits against the potential harms for women participating in a study. Even after having consented to HIV testing, women should have the right not to be told their result.

Reflections on trauma and violence-related deaths in Soweto, July 1990-June 1991.
Byarugaba J, Kielkowski D
S Afr Med J 1994 Sep;84(9):610-4

This is a retrospective analysis of 5,600 deaths registered in Soweto from July 1990 to June 1991. The impact of trauma and violence on the overall mortality pattern was assessed. The majority of deaths occurred in people under the age of 50 years and more men died than women. In 40% of male deaths, the cause was stated as 'ill-defined' or 'unknown'; this was the case in an even higher percentage of female deaths (50.5%). Trauma or violence accounted for 28.5% of all deaths. The gender difference was particularly visible in the trauma category, viz. 89.5% and 10.5% in men and women respectively. Young men (20-29 years) were particularly affected by trauma and violence-related deaths (38.5%). The major types of injuries inflicted were gunshot wounds (33%), unspecified multiple injuries (32%) and stab wounds (27%). Motor vehicle accidents accounted for only 8% of deaths. The urgent need for intervention programmes to prevent unnecessary loss of life, targeted especially at young adults and children, is highlighted.

Imaginary constructions and forensic reconstructions of fatal violence against women: implications for community violence prevention.
Butchart A, Lerer LB, Blanche MT
Forensic Sci Int 1994 Jan;64(1):21-34

The almost exclusive media focus on political violence in South Africa has deflected attention from the high levels of interpersonal violence in areas of socioeconomic deprivation. In order to explore the tension between an at-risk community's perspective and the current reality of violence against women, imaginary constructions of their own violent death produced by 45 African female interview respondents were examined in conjunction with forensic data relating to 73 African female homicide victims in Cape Town, South Africa.

The prototypical account of an imagined homicide involved a female commuter being approached by a group of men, taunted and assaulted, raped and then killed. The majority of actual homicides occurred at or in the vicinity of the residence of the victim, with the attacker being known to the deceased. Whilst only 1 of the imagined homicide narratives depicted the use of alcohol by the victim, over half the actual homicides had elevated postmortem blood alcohol levels.

These and other disjunctions and convergencies between lay and forensic constructions of violent female death should be viewed in the wider context of enmeshment insocial circumstance, and could provide some understanding of how at-risk communities perceive violence against women, thereby providing a foundation for appropriate prevention programmes.

Is the foetal alcohol syndrome child protected by South African law?
Lupton ML
Med Law 1994;13(1-2):79-94

It is scientifically indisputable that excessive use of alcohol or drugs during pregnancy causes defects in the children who are subsequently born to the abusing mothers. In the United States any legislative intervention by a state during the pregnancy would affect the rights of both the mother and the foetus. In order to remain within the bounds of constitutionality any maternal health legislation would have to strike a clear balance between the mother's rights to reproductive and familial privacy and bodily integrity guaranteed by the Fourteenth Amendment and the state's right to protect the foetus. This balance is currently achieved in terms of the framework set out by the Supreme Court in Roe v Wade 410 US 113 (1973).

Although South African legislation cannot as yet be tested for its constitutionality the basic problem of balancing the rights of the mother, the foetus and the state remain the same. South Africa enjoys an advantage which the United States of America does not, viz the common-law remedies presented by the Aquilian action and the actio injuriarum. Only a person can be the bearer of rights and can thus invoke an action to protect those rights. It is thus necessary to determine whether the nasciturus fiction as enunciated in D 1.5.7 would enable a foetus (via a curator ad litem) to enforce rights against its mother. It is submitted that an extension of certain principles in the decisions of our Supreme Court in Christian League of Southern Africa v Rall 1981 (2) SA 821 (O), Wood v Ondangwa Tribal Authority 1975 (2) SA 294 (A) and Clark v Hurst NO 1992 (4) SA 630 (D) coupled to the nasciturus fiction are indicative of the fact that a foetus may enjoy protection against drug abuse by its mother prior to its birth.

The legal implications of abuse of the unborn foetus.
Johnson L
Med Law 1994;13(1-2):19-27

This article looks at the use of psychoactive drugs by pregnant women and theeffects of these on the foetus. Firstly it discusses the historical awareness of alcohol related birth defects, and then the symptoms of foetal alcohol syndrome. There is also the condition known as foetal alcohol effects--a milder version of foetal alcohol syndrome--exhibited by children of alcohol abusing mothers. Secondly, various drugs, both legal and illegal, over the counter and prescription drugs, and their effects on the foetus are examined. Thirdly, the moral, ethical and legal problems facing the health care worker when dealing with a pregnant women who will not or cannot stop using a potentially harmful chemical, are probed in terms of the South African Child Care Act 74 of 1983.

Finally a plea is made for more research in this area, and also that coercive treatment and commital procedures should only be applied when all other methods for treatment have failed.

Brutality to twins in south-eastern Nigeria: what is the existing situation?
Asindi AA, Young M, Etuk I, Udo JJ
West Afr J Med 1993 Jul-Sep;12(3):148-52

Following rumors of some persistence of abuse on twins, a survey was conducted from January through June, 1991 in the rural areas of Efik, Ibibio and Annang tribes of South-Eastern Nigeria to determine the current attitude of the people towards twins and their mothers. Of the 619 women interviewed, 56% cherished having twins; 35% would not desire largely because of the economic and other minor difficulties associated with their up-keep but none of these would abandon the infants. The remaining 9% hold a taboo against twins: as babies derived from the devil, non-human and punishment from the gods for sinfulness. Consequently, 2.3% and 2.6% of the mothers would have their twins rejected and killed respectively and 6% of the twin mothers would be cast out but none killed by their husbands' families. The intention to perpetuate this form of abuse was elicited in all the three tribes but seemed relatively to be most pronounced in Annang people. The information generated, though limited to rural population, suggests that the rejection of twin births has actually not yet disappeared from this part of the country. Health workers in South-Eastern Nigeria who encounter twins with failure to thrive should consider rejection as a possible contributing factor. It would need intensive moral education and religious teaching to stem this brutal culture.

The impact of war on children's health in Mozambique.
Cliff J, Noormahomed AR
Soc Sci Med 1993 Apr;36(7):843-8BR>

them. Since 1982, South African destabilization of Mozambique has caused children's health to deteriorate. Destabilization has functioned through support of a surrogate movement and economic pressure. Attacks on economic and civilian targets have included the health services, leading to closure of 48% of the primary health care network. The war has caused displacement of over 3,000,000 persons and an estimated 494,000 excess childhood deaths between 1981 and 1988. An estimated 200,000 children have been separated from their families or orphaned; many children have also witnessed atrocities and suffered violence. A deepening economic crisis has been followed by an economic structural adjustment programme. Responses to the war include changes in vaccination strategy and programmes to reunite families and heal psychological trauma.

Interpersonal violence: patterns in a Basotho community.
van Geldermalsen AA, Van der Stuyft P
J Trop Med Hyg 1993 Apr;96(2):93-9

This study was conducted to quantify the importance of trauma and death due to interpersonal violence in rural Lesotho and to gain an insight into the profile of the assault victims, the circumstances of the violent incidents and the type of weapons wielded and wounds inflicted.

During a one-year period starting June 1988 information was recorded on all patients with assault trauma attending Quthing District Hospital. The annual incidence rate of assault on men between 20 and 49, the most affected age group, was estimated to be as high as 30 per 1000.

The crude homicide rate could reliably be calculated as 44 per 100,000 per year. The male to female sex ratio amongst the 506 identified victims was 1.7:1. The assailants were male in 89% of the incidents; other men were their victim in 68% of these events. Only 26% of the consulting women suffered at the hands of their husband or partner. Over 55% of injuries (and deaths) inflicted by men were caused by beating with traditional sticks; 15% were due to stabbing. Women used stones, teeth or bare hands and feet equally frequently.

The limited presence of firearms may have prevented higher death rates. It is suggested that the disruption of the social structure of the Basotho society through its dependence on migrant labour leads to weakened normative reference, the moral net, which is the underlying cause for the serious violence problem of the country.

Women, homicide and alcohol in Cape Town, South Africa.
Lerer LB
Forensic Sci Int 1992 Jul;55(1):93-9

Little is known about the complex circumstances culminating in the homicidal death of a woman. The records of 248 female homicides and suicides admitted to the Salt River State Mortuary between January 1990 and July 1991 were reviewed with specific attention to mode of death and blood alcohol concentration (BAC). Female homicide levels reflected the intensity of violence in specific residential areas. White females were far more likely to die a suicidal, as opposed to homicidal, death (Odds Ratio = 31.94; 95% Confidence Interval, 11.63-90.24). Blunt homicide predominated amongst White females, who were substantially older than the Coloured and African subjects. A BAC greater than 0.1 g per 100 ml was found in 56% of all female homicides studied. An association was found between increasing BAC and sharp homicide amongst women. A high BAC may represent a self-destructive element in a risk-taking situation amongst female homicide victims.

Maintenance payments for child support in southern Africa: using law to promote family planning.
Armstrong A
Stud Fam Plann 1992 Jul-Aug;23(4):217-28

This article presents some of the legal, social, cultural, and practical constraints facing women who attempt to enforce their right to maintenance (child support) payments in southern Africa. It is based on research by the Women and Law in Southern Africa Trust, a network of women who research women's legal rights in six countries: Botswana, Lesotho, Mozambique, Swaziland, Zambia, and Zimbabwe. Statutes in all countries in the region provide that a man must support his legitimate and illegitimate children; there are, however, weaknesses in the laws on the books. The social and cultural constraints that influence the enforcement of maintenance laws include women's lack of knowledge of the law, attitudes toward child support influenced by customary law, allegations of women's abuse of maintenance payments, financial and practical problems, and fear of physical violence or other forms of retribution. Maintenance laws are relevant to family planning in that if such laws were more effectively enforced, so that the financial burden of children were more equally shared between women and men, men would have a financial stake in controlling their fertility.

Helping Victims of Violence in UgandaBracken PJ, Giller JE, Kabaganda S
Med War 1992 Jul-Sep;8(3):155-63

We report on a project to assist victims of war and violence in Uganda. The original aim of this project, set up by the Medical Foundation for the Care of Victims of Torture, was to establish a centre for the assessment and treatment of torture victims who had suffered during previous regimes in that country. We found, however, that a specialist centre was not the most appropriate response in a country like Uganda. We argue for the need to respect local initiatives and systems of support and against the notion that there is a single model of care which is universally relevant. Following much investigation and involvement with local personnel, we have developed a programme of training and discussion for health workers, and a service to reach the many women who have suffered rape, and whose suffering has continued, largely ignored.

Nursing student perceptions of public health issues in Ghana.
Braithwaite RL, Moore F, Taylor SE
J Natl Black Nurses Assoc 1992 Spring-Summer;5(2):3-15

This article reports survey results to Ghanaian nursing students' perceptions of public health issues. Their views were ascertained through a questionnaire designed to capture ratings of educational curriculum concerns and perceptions of the importance of public health factors. Both frequency data and chi-square analysis were used to assess the ordinal position of health factors and gender differences, respectively. Chi-square analysis was also done to assess differences by age. Differences between men and women respondents existed on six of 15 health factors (p less than .05) including malaria, heart disease, measles, cancer, malnutrition and car accidents, while differences between age groups were found on two of the 15 factors (violence and cancer). Based on the ascertained student perceptions, current efforts in Ghana suggest that preventive health is an emerging concern to public health officials. As such, Ghanaian nursing students hold perceptions not dissimilar to those of U.S. health professions students.

The relationship between child sexual abuse and adolescent sexual functioning in Afro-American and white American women.
Wyatt GE
Ann N Y Acad Sci 1988;528:111-22

This study has examined the relationship between child sexual abuse and adolescent sexual functioning in a community sample of 245 Afro-American and white American women, most of whom became sexually active during adolescence.

Significant relationships between several aspects of women's child abuse experiences and their voluntary sexual behavior before age 18 revealed that women who reported contact sexual abuse (fondling, and attempted and completed oral and vaginal intercourse) had voluntary sexual intercourse 15.4 months earlier than women with noncontact (e.g., observing exhibitionists) or no abuse.

Likewise, women with contact abuse engaged in necking and petting behaviors at earlier ages, and had more sexual partners during adolescence and briefer sexual relationships than women with noncontact or no abuse. Similar relationships between interviewers' ratings of the severity of child sexual abuse and women's adolescent sexual behaviors were noted.

These findings stress that child sexual abuse, rather than women's ethnicity alone, may contribute to the early onset and frequency of adolescent sexual behaviors. Conceptual formulations that address these relationships and the implications for future research and socialpolicy have been discussed.

Occurrence and characteristics of mandibular fractures in Nairobi, Kenya.
Mwaniki DL, Guthua SW
Br J Oral Maxillofac Surg 1990 Jun;28(3):200-2

Analysis of 355 cases with fractures of the mandible indicated that 74.9% of the cases were due to interpersonal violence and 13.8% were caused by road traffic accidents. The men to women ratio was 8.4:1 and 75.5% of the fracture cases had single fractures while 24.5% had multiple fractures. In cases with a single fracture, the most commonly involved mandibular site was the body (42.2%). The angle of mandible was most frequently fractured (50.5%) in cases with multiple fractures.

Prevalence and sequelae of sexual torture.
Lunde I, Ortmann J
Lancet 1990 Aug 4;336(8710):289-91

283 torture victims (135 examined by the Amnesty International [AI] Danish Medical Group, and 148 by the International Rehabilitation and Research Center for Torture Victims [RCT]) were questioned about methods of torture and subsequent sexual difficulties. Overall, the prevalence of sexual torture was 61% (women 80%, men 56%), but this was higher in the RCT than in the AI group. More Latin Americans than Europeans had been sexually tortured in the AI group. Prevalence of sexual difficulties was 32%, the RCT recording a significantly higher prevalence than the AI (43% vs 20%). Sexually tortured victims were more likely to have sexual difficulties (40%) than were non-sexually tortured victims (19%). Overall, there were more cases of sexual difficulties in victims from Africa and from Turkey/Middle East/Far East than in victims from Latin America and from Europe. In the RCT subsample, prevalence of sexual difficulties and anxiety was significantly higher in sexually tortured victims than in non-sexually tortured victims; the two groups were broadly similar with respect to depression and low self-esteem. Depressed victims and victims with low self-esteem were more likely to have sexual difficulties. In the RCT group, but not overall, prevalence of sexual difficulties was significantly associated with age but was independent of low self-esteem and of depression.

Epidemiology of non-fatal injuries due to external causes in Johannesburg-Soweto. Part II. Incidence and determinants.
Butchart A, Nell V, Yach D, Brown DS, Anderson A, Radebe B, Johnson K
S Afr Med J 1991 Apr 20;79(8):472-9

A total of 3,535 trauma cases were enumerated in Johannesburg-Soweto between 1989 and 1990 in the course of 271 hospital ward rounds and 43 casualty watches

The overall trauma incidence was 2,886 new cases per annum per 100,000 population, rising to 19,872 for coloured males aged 20 - 24 years and to 8,761 for black males aged 20 - 24 years. Overall the male/female ratio was 2.9 rising to 6 or more in adolescence (15 - 19) for blacks and coloureds. There were some 156 new resident cases of trauma daily; half these were victims of interpersonal violence, and coloureds constituted 22% of this group, although forming only 8% of the denominator population. With regards to cause, most trauma among blacks and coloureds arose from interpersonal violence and significantly less from transport accidents. Among blacks injured in transport accidents (the majority of which involved motor vehicles) most were pedestrians, whereas most whites injured in such accidents were occupants of vehicles. For all groups trauma was most likely to be incurred 'in the street' although for white and coloured women the home was most dangerous. The implications of these and related findings for treatment and prevention and briefly reviewed.

Child abuse as an inhibiting factor for family planning.
Fahim HI, Faris R
J Egypt Public Health Assoc 1992;67(1-2):1-11

The aim of this study is to determine the magnitude of the problem of using children as an economic asset to the family thus, in one way increasing the prevalence of child abuse in Egypt and also hindering the family planning program. Two focus-group interviews were conducted in urban & rural areas for 10 women with the same age range and socioeconomic background. All were non-users of any contraception. Subsequently an interview was conducted for all women who attended the Ob. & Gyn. Clinic at Ain Shams University Hospital in the period from June to August 1991, their ages ranged from 30-35 years and they never used contraception. Another group of women with the same characteristics were interviewed from a rural area at Fayoum Governorate. A questionnaire was filled for each interviewed woman. The total women interviewed in urban area is 340 while in the rural area they were 400 women. Sixty percent of urban women and 80% of rural women are illiterate, 70% of the urban & 100% of rural women are housewives. Their years of marriage ranged between 10-20 years and all of them have more than five children. A percentage of 73.5% of urban women and 85% of rural women stated that children are used as an economic asset to their families, they work in urban areas as assistants in motor repairs, hair-dressers, beggars, bakeries, shops, restaurants and factories while in rural areas they work as agricultural workers.

THE IMPACT OF VIOLENCE AGAINST WOMEN ON SEXUAL AND REPRODUCTIVE HEALTH

Introduction:
One of the most significant achievements of the last decade of the millennium has been the recognition given by the United Nations and a growing number of governments, including that of South Africa, that violence against women is a human rights issue. In 1993 the United National General Assembly adopted a declaration which for the first time offers an official UN definition of gender-based abuse. According to Article 1 of the declaration, violence against women includes:

"Any act of gender-based violence that results in or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private life."

Article 2 of the Declaration states that the definition should be understood to encompass, but not be limited to, physical, sexual and psychological violence occurring in the family and in the community, including battering, sexual abuse of female children, dowry-related violence, marital rape, female genital mutilation (FGM) and other traditional practices harmful to women, non-spousal violence, violence related to exploitation, sexual harassment, and intimidation at work, in educational institutions, and elsewhere, trafficking in women, forced prostitution, and violence perpetrated or condoned by the state.

Whilst this is a very significant development, in most countries there has been very little policy attention given to addressing violence against women as a public health issue and even less to tackling its underlying causes. Violence against women impacts on sexual and reproductive health in multiple ways and the eradication of this violence must become an integral part of efforts to promote the sexual and reproductive health of women worldwide.

Magnitude of Gender-Based violence:
Understanding of the magnitude of the problem of gender-based violence and its causative factors and mechanisms is greatly hampered by the lack of well-designed population-based studies in many countries. Although there is research in progress in many countries, coordinated through the World Health Organization (WHO), most of the completed in-depth research has been from North America. Data on the prevalence of rape is even more difficult to find. The data from South Africa collected from representative community-based studies gives some idea of the magnitude of the problem in this country. In the 1998 Demographic & Health Survey, 4.4% of all women interviewed aged 15-49 reported having ever been raped. This figure was actually lower than the researchers had expected to find given that studies of teenage sexuality have found almost one third of teenage girls reporting forced sexual initiation (e.g. Buga et al 1996, Richter 1996). Gender-based violence usually continues during pregnancy and may take different forms and have different consequences. In recent research from South Africa, women were asked about whether they had experienced different types of abuse during pregnancy. The results are presented below. These findings were very similar to those of research undertaken in Zimbabwe in 1996.

• Teenage pregnancy
  Teenage pregnancy is regarded as a major problem in many countries. In South Africa, for example, 35% of women under 20 years have been pregnant or have a child (Department of Health, 1999). Since marriage is late, most of these young women are unmarried and still at school. Teenage pregnancy reduces the likelihood of the mother completing schooling, reduces prospects for subsequent employment and earnings, compromises the financial position of her family's household (maintenance from the father is rarely forthcoming), and negatively impacts on the child, who is born into relatively greater poverty.

  In South Africa, research into teenage pregnancy has shown that after adjusting for socio-economic and other factors, forced sexual initiation was found to increase the risk of teenage pregnancy by14 times (Vundule et al, forthcoming). Forced sexual initiation was found to have a major impact on the likelihood of pregnancy occurring years later. In the USA, women raped in childhood were three times as likely to have teenage pregnancies (Zierler et al 1991).

• High risk sexual practices
  High risk sexual practices - including having sex for material reward, having multiple partners and casual partners - are associated with a greater likelihood of unwanted pregnancy, STDs and HIV infection. Research in several countries has shown that child sexual abuse is associated with increased risk of unsafe sexual practices. Handwerker (1993) showed that in Barbados, the most important determinant of high risk sexual activity amongst adolescents was child sexual abuse. In the USA, women raped in childhood were four times as likely to go into prostitution and twice as likely to have casual sexual partners (Zierler et al 1991).
• HIV/STDS
  HIV poses a major threat to the lives of a very substantial number of Commonwealth citizens. In South Africa, at the end of 1998, three million were estimated to be infected with the virus. HIV transmission again is facilitated in multiple ways by gender-based violence. The most obvious form is during rape. There is a lack of research on the likelihood of HIV infection after rape, but there is some data on transmission of STDs. For example, in a study organized by a women's NGO in Thailand, 10 percent of raped women were found to have acquired STDs (Archavanitkni & Pramualvatana 1990).

  Violence or the fear of violence has been shown to reduce women's ability to negotiate condom use (Heise et al 1993). In many cultures suggesting condom use is tantamount to implying or admitting infidelity, as condoms are associated with prostitution, promiscuity and disease. A suggestion of condom use can be perceived as an implicit challenge to a male's right to have many women.

  At the same time many women know that their partners have other sexual partners. In South Africa, for example, a common form of emotional abuse of a spouse involves boasting about or bringing home other women to have sex with them in the marital bed. Recent research found that 10 percent of women in one province reported that their spouse had done this in the previous year (Jewkes et al 1999).

  In many cultures women who are married or living with a man perceive that they cannot refuse his requests for sex. This undermines their ability to use this as a sanction to enforce condom use, even if their partner has a visible STD. In South African research, for example, 57% of women living in the Eastern Cape believed that they could not refuse sex with their partner (Jewkes et al 1999). In the light of all this it is perhaps not surprising that this study also found that HIV prevention was discussed significantly less often in relationships with physical violence.

  A further source of vulnerability to HIV infection stems from sexual harassment and exploitation of schoolgirls by older men, and particularly school teachers. This renders these girls extremely vulnerable to HIV and explains why in a country like South Africa the HIV epidemic in young women starts and peaks some five years earlier than in young men.

• Pregnancy Outcomes
  Although there is controversy about whether women who are pregnant experience more abuse than non-pregnant women, gender-based violence has been associated with poor perinatal outcomes. Partner battering has been identified in several countries as an appreciable cause of maternal mortality. The most recent reports of confidential enquiries into maternal deaths in South Africa and in the UK have both identified gender-based violence as causes of death (Department of Health 1998, Department of Health,1999b).

  Domestic violence has been associated with foetal distress and foetal death at all stages (Dye et al 1995). The 1998 South Africa Demographic & Health Survey data shows that women who had been physically abused by an intimate partner in the past were twice as likely (12.1 percent against 6.3 percent) to have experienced pregnancy loss as non-abused women. This difference was statistically significant. The same study also showed that stillbirths were higher for women who had been abused by an intimate partner in the past. These women reported 15 stillbirths per thousand women, compared with 10 per thousand amongst women who had never been abused.

  The table on abuse on pregnancy presented earlier shows that abusive spouses often prevent women from using antenatal care. This finding has also been confirmed by the 1998 South Africa Demographic & Health Survey data which shows that women who had been physically abused by an intimate partner in the past were less likely to have had antenatal care than non-abused women (18 percent against 21 percent).

Medical Research Council
Private Bag X385, Pretoria 0001, South Africa
Tel: 021 339 8525
Fax: 021 339 8582
Email: R Jewkes

References:

Archavanitkui K, Pramualratana A (1990) Factors affecting women's health in Thailand. Paper presented at the Workshop on Women's Health in Southeast Asia, population Council, Jakata, October 29-31. Bergman B, Brismar B, Nordin C (1992) "Utilisation of Medical Care by Abused Women". BMJ 305. 27-28.

Buga GAB, Amoko DHA, Ncayiyana D. (1996) "Sexual Behaviour, Contraceptive Practices and Reproductive Health Among School Adolescents in Rural Transkei". South African Medical Journal 86,523-527.

Department of Health (1999) South Africa Demographic and Health Survey. Preliminary report. Department of Health, Pretoria.

Departments of Health (1999b) Saving Mothers. Report on Confidential Enquiries into Maternal Deaths in South Africa 1998. Department of Health, Pretoria.

Department of Health, Welsh Office, Scottish Office Department of Health, Department of Health and Social Services NI (1998) Why Mothers Die. Report of Confidential Enquiries into Maternal Deaths in the United Kingdom 1994-1996. TSO, London.

Dye TD, Tollivert NJ, Lee RV, Kenney CJ (1995) "Violence, Pregnancy and Birth Outcome in Appalacia". Paediatric and Perinatal Epidemiology, 9, 35-47.

Handwerker P (1993) Power, Gender Violence and High Risk Sexual Behaviour: AIDS/STD Risk Factors Need to be Defined More Broadly. Humboldt State University, Department of Anthropology. Heise L, Pitanguay J, Germain A (1993) Violence Against Women. The Hidden Health Burden. World Bank Discussion Paper 255.

Jewkes R, Penn-Kekana L, Levin L, Ratsaka M, Schrieber M (1999) He must give me Money, He mustn't beat me: Violence against women in three South African Provinces. Medical Research Council Technical Report, Pretoria.

McFarlane J, Parker B, Soeken K (1996) "Abuse During Pregnancy: Associations with Maternal Health and Infant Birth Weight". Nursing Research 45, 37-42.

Vundule C, Maforah NF, Jewkes R, Jordaan E (in press) "Risk Factors for Teenage Pregnancy Amongst African Adolescents in Metropolitan Cape Town: A Case Control Study". South African Medical Journal

RECOGNISING AND REDUCING BAARRIERS TO CATARACT SURGERY

Cost of Surgery
The cost of cataract surgery varies widely and may be more than poor people, with little or no dispoasable income, can afford. It would be a mistake to assume, however, that providing free cataract surgery automatically leads to high cataract surgical coverage. In addition to the surgery itself, there are other costs such as transportation or the carer accompanying the patient, and living expenses for the carer while the patient is in the hospital. In Nepal, these non-surgical costs alone were estimated to be one-fifth of the annual income of a rural patient.1 In India, reducing the cost of surgery and providing transportation expenses for the patient has significantly increased the acceptance of catartact surgery.2 Studies in India have demonstrated that most people are willing to pay approximately the average monthly income of their families for high quality cataract surgery. There have been innovative approaches to provide high quality services at a lower cost, and testing and implementing these in other settings should become a priority.

Cost, as a barrier, may be reduced by:

• Decreasing the costs of surgery by reducing the cost of supplies and equipment and improving efficiency
• Implementing different pricing mechanisms to make sure that the poor can receive surgery even if they cannot pay
• Reducing the non surgical costs such as transportation and expenses for careers

Distance to the Hospital
Most cataract blind live in rural areas while most ophthalmologists live inurban areas. Use of western medical services (including those for cataract) is related to proximity; people who live far from a hospital tend not to use its services. In Malwi, traditional healers who live far from the hospital provide more ‘cataract treatment’ than traditional healers living near hospitals.3 People will use what is most available to them first.

Distance as a barrier may be reduced by:

• Setting up outreach programmes in rural areas
• Providing transportation (from villages direct to the hospital and return)

Cultural and Socail Barriers
There is an increasing amount of data demonstrating that women are significantly less likely to receive cataract surgery than men, inspite of the fact that cataract surgical rates in women are slightly higher than those in men. There are many reasons for this: women are less likely to be literate and have access to information about services; women many not have the necessary social support within the household or community to allow them to receive care; women often do not have adequate control over household financial resources, and women are generally less able to travel outside the village to seek services.

The concept of blindness is understood differently in different societies and differently among members of the same society. Generally, as societies become more developed, expectations of vision increase. In any society, a patient’s visual function (a measurement of th eimportant vision-dependent tasks that he or she can do) is a more important measure of the need for cataract surgery thaan visual acuity alone. In one developing country, being turned away because the cataract was not yet ‘mature’ was a major reason given by blind patients for not having surgery.

Cultural and social factors as barriers may be reduced by:

• Targeting educational efforts in women’s groups
• Creating support mechanisms for elderly women
• Teaching the public that blindness is not an inevitable part of ageing
• Educating health care personnel about visual function and its importance in selecting patients for cataract surgery
• Making eye care services ‘user friendly’ and so culturally acceptable

Knowledge of services
Community based education about cataract has not been undertaken in most areas; when it is, the demand for surgery will incresse. Not only mus patients be made aware of the existence of the service, but they need to know what to expect:

• How long surgery will take
• What will it cost?
• Will it be painful

Health care workers at the village level must be made aware of existing services.

Lack of knowledge of services as a barrier may be reduced by:

• Using helath workers (including community based rehabilitation workers) and/or traditional healers to find, screen and educate patients
• Using successfully operated patients as educators and motivtors
• Educationa campaigns using available media resources

Trust in Outcome of Surgery
While satisfied cataract patients can serve as excellen motivators for others to have surgery, patients with peoor results can have the opposite effect. Fear of a poor outcome may be a legitimate reason for patients to refuse cataract surgery. Programmes must provide consistently high quality cataract surgery with good outcomes if patients are to develop trust in the programme. It has been shown in India that the conversion from aphakic spectacles ot IOLs led ot a significant increase in cataract surgical coverage. In cultures (e.g Egypt, Tibet) in which women do not like to wear glasses, the conversion to high quality IOLs may help decrease the gap between men and women.

Lack of trust in a good outcome as a barrier may be reduced by:

• Additional training of surgeons to ensure that cataract surgery is high quality (monitoring of outcomes may assist this)
• Transition to IOL surgery as soon as possible
• Avoding waiting lists which mean that patients have to return foe surgery

Barriers will vary according to local conditions and customs. Conservaations with patients, village leaders, and women’s groups may confirm the existence of barriers such as those listed above or reveal unexpected ones. Programmes planning to increase cataract surgical rates will need to determine the barriers I each area, whether relating to costs, distance, cultural/social facors, anxiety/fear or other barriers, and final creative ways to overcome them.

GRAIN FOUND GROWING IN THE EYE

The symptoms became aggravated and the child was brought to the hospital again after four or five days. After a double eversion of the upper lid, the grain was found with a shoot growing inside the eye. Fortunately there was no corneal ulcer and the eye could be saved.

This led us to organise campaigns for the use of protective glasses while threshing paddy with electrically operated machines. With the use of electrically operated machines, the grains enter the eyes with greater force and cause much more injury to the cornea. The fine hairs of th epaddy grain have a notorius tendency to push the grain up into the upper fornix an dhide there. Double eversion is the technique to detect it.

DEATH AND THE SECOND SEX

Many women concur that dry sex, as this practice is called, hurts. Yet it is common throughout southern Africa, where the AIDS epidemic is worse than anywhere in the world. Researchers conducting a study in Zimbabwe, where Mhakeni lives, had trouble finding a control group of women who did not engage in some form of the practice. Some women dry out their vaginas with mutendo wegudo -- soil with baboon urine -- that they obtain from traditional healers, while others use detergents, salt, cotton, or shredded newspaper. Research shows that dry sex causes vaginal lacerations and suppresses the vagina's natural bacteria, both of which increase the likelihood of HIV infection. And some AIDS workers believe the extra friction makes condoms tear more easily.

Dry sex is not the only way African women subordinate their sexual safety to men's pleasure. In a few cultures, a woman's vagina is kept tight by sewing it almost shut. But in most African societies, the methods are subtler: Girls are socialized to yield sexual decision-making to men. Prisca Mhlolo is in charge of counseling at The Centre, a large organization for HIV-positive Zimbabweans. "You're not even allowed to say, 'Can we have sex?' " she notes. "So it's very hard to bring up condoms."

Mhlolo speaks from both professional and personal experience. She is HIV-positive, infected by her late husband. As AIDS eroded his immune system, he suffered from herpes, which broke into open sores on his penis. Mhlolo suggested condoms, "but he said, 'Now that I'm sick you have gotten yourself a boyfriend.' It was very hard."

Many people balk at discussing the sexual practices of particular cultures because the issue is too sensitive -- and, in Africa, too racially charged. Whites have caricatured African sexuality for centuries, casting black men as sexual beasts, and some whites still whisper that this is why HIV is running rampant among Africans. But such stereotypes miss the point, which is not the libido itself but the culture in which it finds expression. HIV spread through the American gay community because having anal sex with many partners was common, and the virus infiltrated the Thai army because soldiers routinely patronized prostitutes. In Bombay, where AIDS has exploded, slum lords demand payment in sex. I.V. drug use aside, male sexual privilege is what drives the epidemic.

Studies from many different cultures show that men average more partners than women do and have more sex outside marriage. Because a man ejaculates into a woman, men are more likely to transmit the virus, whereas women are more likely to contract HIV without passing it on. So far, males have outnumbered females in HIV cases, partly because having more partners means more chances to encounter the virus. But new figures show that in sub-Saharan Africa, 55 percent of all infected adults are women.

Of course, Africa contains thousands of cultures, some of which have strict sexual codes. But common to many sub-Saharan societies are the gender roles epitomized by dry sex: Women are unable to negotiate sex, and so must risk infection to please the man. In fact, there are very few female checks and balances on male behavior. This stark inequality "is part of our culture," Mhlolo says, "and our culture is part of why HIV is spreading."

Africa today is far removed from its traditional, tightly knit communities that did constrain men, mostly to their wives. Africa is also very different from the West, where women exercise a relatively large degree of power. Many parts of contemporary Africa are suspended in a limbo that combines the worst of both worlds, and HIV has exploited this. For example, men retain the mindset of polygamy, but now have many partners through commercial sex or "sugar daddy" relationships that lack the social cohesion of traditional marriages. But AIDS is forcing African culture to change -- and because the virus in Africa is spread mainly through heterosexual sex, the epidemic's largest social transformation may well be in the relations between women and men. Women could emerge from the epidemic with more power, and there is a strong push to make that happen. But there is also a backlash, a call to reimpose restrictions on women in the name of strengthening traditional African cultures and curtailing AIDS.

The battles are being fought not only over sexual practices, but also over larger economic and social forces that subordinate women and facilitate the spread of HIV. The World Bank reports that illiteracy rates among women south of the Sahara are almost 50 percent higher than among men. Many African girls cannot attend school because they are assigned time-consuming chores such as fetching water and firewood. Indeed, African women work longer than men -- and harder. Studies from Ghana and Tanzania show that rural women transport four times as much as men, often carrying the loads on their head, and other studies show that women do up to 90 percent of hoeing and weeding. Yet they make far less money than men and rarely own property. In Cameroon, for example, fewer than 10 percent of all land certificates belong to women. African women also lack authority. Just this year, Zimbabwe's Supreme Court ruled that women have no more status or rights in the family than a "junior male" -- usually an adolescent. If a wife wants to take a trip, explains Thoko Matshe, director of the Women's Resource Center in the capital Harare, "she has to sit her husband down, get the guy in a good mood, and ask him if she can go. If you cannot negotiate that, you cannot negotiate sex."

In most sub-Saharan traditional cultures, men pay for their wives, which gives them license to dominate the relationship. The very concept of marital rape doesn't exist in most of Africa, and even the aunties -- traditional marriage counselors for many young African wives -- tell women that they cannot refuse sex with their husbands. Thoko Ngwenya of Zimbabwe's Musasa Project, which fights domestic violence, explains the mindset: "Once a man has paid lobola" -- the word for dowry in several southern African languages -- "they are not forcing their wife to have sex. It's just their right."

The sexual subservience of women is inculcated long before adulthood. For example, traditional Shona girls are taught to pull the lips of their labia to lengthen them so that men can play with them during foreplay, yet women are not supposed to touch their husband's penis. Indeed, in some cultures, female circumcision removes the most sexually sensitive part of a woman's body -- her clitoris. "For women," says Caroline Maposhere of Zimbabwe's Women and AIDS Support Network, "there is no sexuality, only fertility." Ironically, the prohibition against wives participating fully and actively in sex can itself promote the spread of the virus. Eliot Ma-gunje runs counseling groups for men at The Centre. He hears men complain that their wives' passivity "destroys the enjoyment of sex -- she's just lying there like a log. 'Why are we going out?' men ask. 'Because a prostitute is 100 percent what I want. My wife is just for cooking and washing.' "

Of course, real-life relations between men and women are more complex. Jane, a Zimbabwean woman who asked that her last name not be used, says, "If your husband demands sex you are not allowed to deny him, but in practice you communicate and understand each other." The trouble is that such communication takes place on a field steeply tilted in favor of the man. Jane, for example, knew that her husband had a girlfriend on the side, and she took the step of asking him to use a condom. "My husband answered, 'I cannot use a condom with my wife,' " Jane recalls. "So I think that's why I got infected." She's not alone. A study from Zimbabwe found that more than half of women with STDs contracted their illnesses from their husbands. Marriage, say many AIDS workers, is a risk factor.

Anecdotal reports indicate that dry sex is waning among educated, urban young people. But there are also loud calls to reject Western gender roles, which are said to emasculate men. Even in the cities, says Matshe, "it's 50-50." Of course, most Africans still live in rural areas or small towns. And changing sexual practices is never easy, in part because they touch fundamental issues of personal identity and sexual roles. It's not surprising that men like dry sex -- the swollen tissues make the vagina smaller and, therefore, make the man feel bigger. Also, some men (and women) find vaginal secretions repugnant, while others don't like the sound of wet sex. And to many men, a vagina that is too wet and loose can signify infidelity.

But some women also prefer dry sex. Mhakeni stopped only because she is HIV-positive and wants to protect herself against getting any sexually transmitted diseases that might weaken her immune system. Despite the pain of dry sex, she favors it. "It's our culture," she explains. Then she adds a reason researchers and AIDS workers say they hear over and over again: "If I don't use herbs, our men will go with someone else." Indeed, Mhakeni sells the herbs, and even when she warns women of the risks, they still buy. "They say, 'It is okay if HIV is brought in by my husband, because at least I will still be married.' "

Fanuel Adala Otuko looks every inch the leader of Kenya's Luo people: old, ramrod straight, missing six lower teeth pulled at age 12 as a rite of passage. "It is painful," he says, "but you cannot cry." The Luos no longer pull their children's teeth, but Otuko and other elders want to revive some of the Luo's other traditions, especially those they believe might slow the spread of HIV, which has devastated them. In Kenya, Luo land is one of the hardest-hit areas in the country, with the rate of infection among adults in Kisumu, the city where Otuko lives, topping 20 percent. All over Africa, AIDS workers are beginning to target male behavior. Around Kisumu, they are especially concerned about the fish merchants on the shores of Lake Victoria, who lure young girls with money. But Otuko and other Luo elders focus on women.

For example, the elders want to revive the ideal of female virginity. Traditionally, on the afternoon of a wedding, a dozen or more married women went to the newlyweds' home to check for blood, believed to be a sign of a woman's virginity. They also checked the man -- not for virginity, but for sexual prowess. They "witness that she has a normal man," explains Otuko, "a man who can have sexual relations with her." The elders also want to take more aggressive steps. Against the recommendations of most public-health workers, they want to identify HIV-positive women and impose restrictions on them. "They should be controlled, quarantined in their areas," Otuko says. (Only when asked does he say that this restriction could also apply to men.) "AIDS is serious," he says. "There is no cure. So people should avoid contact with infected women, sexual contact especially." There's the rub, because one venerated Luo tradition usually involves sex with a widow -- and AIDS has caused a proliferation of widows.

Like many cultures in East and southern Africa, the Luo practice what is variously translated as home guardianship or, more commonly, widow inheritance. When a husband dies, one of his brothers or cousins marries the widow. This tradition guaranteed that the children would remain in the late husband's clan -- after all, they had paid a dowry for the woman -- and it also ensured that the widow and her children were provided for. When the guardian takes the widow, sexual intercourse is believed to "cleanse" her of the devils of death. A woman who refuses to take a guardian brings down chira -- ill fortune -- on the entire clan. Of course, if her husband died of AIDS, she might very well pass on the virus to her guardian. Millicent Obaso, a Luo public-health worker with the Red Cross, says: "We have homes where all the males have died because of this widow inheritance."

Danger to the inheritors is only one reason AIDS is putting this tradition under strain. Guardians are supposed to provide assistance, but even the elders concede that inheritors often take a widow only for sexual pleasure or to seize her property. According to tradition, a guardian must already have a wife of his own, so no matter how well-intentioned he may be, poverty often makes it impossible to support a second family. Anna Adhiambo is standing where she and her husband used to live: in Ngeri village, on a fertile hillside that slopes down into the blue expanse of Lake Victoria. It's the first time she has been back since her late husband's family forced her off the property two years ago. Her husband died of AIDS in 1996, and she was inherited by his cousin. She expected him to help her feed her three children and pay their school fees (education in Kenya, as in most African countries, is not free). But he was a fisherman who had a family of his own, and "whenever he came from the lake," Anna recalls, "he said he didn't have enough. That was the song." They quarreled frequently, and five months after she was inherited, Anna decided to separate.

The consequences were swift and harsh. A group of men from the clan told her she and her children would have to leave the next day. She remembers that they called her an ochot, a whore who "goes from one man to another." When she asked them to "please leave me alone in my house," she recalls one of her brothers-in-law retorting, "This is our home. You shouldn't answer me rudely like that, and if you do so again, I will beat you." Consolata Atieno is Anna's mother-in-law. She has been smoothing the earthen walls of a new hut, and on her hands the thick mud dries and cracks as she talks. Anna "violated tradition, broke a taboo," she says, so "we had to chase her and her children away. We felt the furniture and things in the house were my son's, so we took them. Anna did not buy them. And the land we took: Some we gave to my other sons, some we sold. In our tradition, a woman is the property of her husband's family. He bought her with the dowry."

Unable to farm, Anna now makes less than $10 a month doing odd jobs in a nearby town. The Akado Women's Group, a local agency, is assisting her, but so far only one of her three children is in school. How does Atieno feel about her grandchildren suffering? "When Anna was making this decision, she must have known the consequences." But if Anna cannot provide for them, her children will be at greater risk for continuing the cycle of infection. A study in Zambia, for example, found that a lack of education quadrupled the chances that a woman would contract HIV. Otuko and the elders believe home guardianship could strengthen families like Anna's. What the elders want is to strip this tradition of its sexual component, transforming it into what they call "symbolic inheritance." They point out that nonsexual cleansing was practiced with aged widows who were past menopause. And in parts of Zambia and Zimbabwe, such symbolic rites have gained ground.

University of Nairobi philosophy professor Oriare Nyarwath believes nonsexual inheritance could bring "a dignified death to the practice, without making people feel culturally destitute." But, he notes, even symbolic guardianship implies that women are subservient to and dependent upon men. "The culture is patrilineal and patriarchal," he says. "The woman goes to live in the man's home, the woman fits within the man's culture. So necessarily she's not on the same footing as the man." The most pernicious inequality is poverty, by no means a uniquely African phenomenon. Of the world's 1.3 billion living in abject poverty, 70 percent are women -- and most of them face the same basic problems as African women. "In pre-industrial societies women are trapped in their reproductive roles," says Geeta Rao Gupta, president of the International Center for Research on Women. In ICRW's numerous studies on HIV, women from Latin America, Asia, and Africa report that they dare not insist on safer sex -- or object to painful sex -- for fear of being abandoned by their men and spiraling down into destitution. No wonder that in a 19-country study, ICRW found that the lower women's status, the higher HIV.

There are few places where poverty is worse than in Nairobi's slums, vast warrens of tin shanties, open sewers, and garbage-strewn dirt roads. In Korogocho, one of the poorest and meanest sections, a maze of narrow passageways leads into a one-room shack where the aroma of vegetable stew simmering on an open fire competes with the stench of raw sewage wafting in from outside. This is the home of Mary, who asked that her last name not be used. Two babies -- Mary's seventh child and her first grandchild -- lie on the bed. Just a week ago, one of Mary's johns -- who pay as little as 75 cents for sex -- slapped her in the face when she asked him to use a condom. "I can't eat a sweet in its wrapper," he said. Flashing back eight years to the man who beat her so viciously that she couldn't work for two days, she let her latest violent customer go ahead. He may pay for his pleasure with AIDS, because Mary is HIV-positive.

Mary wasn't born in the slums, but in a rural area 100 kilometers outside of Nairobi. There, rich red earth nourishes broad green leaves of the plantain tree, the billowing shrubbery of coffee plants, and the yellow-tufted stalks of maize. Mary's mother Beth sits in a hut, the door propped open with a machete, and explains why her daughter left. Her account corresponds exactly to the one given independently by her daughter. The tale they tell is an allegory of how women's powerlessness fuels the AIDS epidemic. Mary's husband "was a drunkard," Beth says. He beat Mary virtually every week, burned her clothes, and denied her food. Once, when he was drubbing Mary, one of their children got in the way. The husband literally threw the seven-year-old girl aside. She landed on a rock, injured her lung, and was hospitalized for two weeks. Mary fled to her parents. At first Mary's father, who died just this year, welcomed her home. But after a few days he realized that Mary and her children were extra mouths to feed. Mary recalls, "My father told me 'I have my own kids, so you're a burden to me. Pack up and go.' "

There are thousands of women like Mary in Nairobi, not to mention all of Africa, and to help curb the spread of HIV they need much more than AIDS awareness. "The women I work with say they'd rather die of AIDS tomorrow than die of hunger today," says Ann Waweru, director of the Voluntary Women's Rehabilitation Centre, an organization that helps sex workers, including Mary, find alternative work. It's not easy. "Most have no skills and no place to get a loan to start a business. A man is almost never burdened with children, so he can do casual work, earn 20 shillings, and survive on that. But most of the women we work with have children. They are driven to commercial sex by poverty."

According to the custom of the Kikuyu people, Mary's brothers were each given a plot of land to farm. But as a female child Mary was given nothing. At first, she tried to stay in the village, supporting herself and her children by doing odd jobs such as drawing water from the well and helping people till their fields. But her father wasn't satisfied and he would beat Mary and her mother. After six months Mary fled for Nairobi with her children and virtually nothing else. In the city, she spent her first night at the home of a friend, who told her, "I'm going to show you how to get money." Mary turned her first john that night, and, she recalls, "I was happy because I got money to feed my children."

Research intern: Christine Brownlee
This article was originally published in the Village Voice
The Body

REQUEST FORM FOR FULL LENGTH TEXT OF ARTICLES:

4) SEND THIS FORM (OR A COPY) AND YOUR LETTERS TO THE FOLLOWING ADDRESS:
Zambia Health Information Digest
Medical Library
University of Zambia, School of Medicine
Tel: 01-250801
Fax: 01-250753
P.O. Box 50110
Lusaka, Zambia
medlib@unza.zm

[ZHID Table of Contents] [Medical Guide Table of Contents] [Zamnet][UNZA][UNZA Library]

Last updated August 30, 2001