During the past six years the public health crisis in the developing world has been getting remarkable attention. In 2000, 189 nations came together at the UN to pledge their support for eight “Millennium Development Goals” including the eradication of extreme poverty and hunger, the reduction of child mortality, and the control of AIDS. Since then, several new public health foundations with billions of dollars to spend have emerged, including the Bill and Melinda Gates Foundation and the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as the less well endowed but no less ambitious William J. Clinton Foundation.
Opinion polls show that voters in the US and Europe are far more willing to support foreign aid programs than they were just a decade ago; and some corporations, such as Gap Inc., Coca-Cola, and De Beers have discovered that associating their brands with philanthropic activities helps sell T-shirts, soft drinks, and diamond rings. Most heartening of all is that, at last, some of these groups are finally beginning to grasp the fundamental reality that they aren’t going to get anywhere near the public health goals they have set themselves unless they deal with the human rights issues, and particularly the rights of women, that underlie most health problems in developing countries.1
The causes of poor health in the developing world are often pathetically simple: lack of access to safe water, vaccines, mosquito nets, antibiotics, oral rehydration salts for diarrhea, and other cheap commodities. Many international health agencies specialize in distributing these items to developing countries and in sponsoring research on new ones, including vaccines for AIDS and malaria that so far do not exist. But there is growing recognition that the key to improving the health of the world’s poor may lie not only in technology but also in politics—and in encouraging poor people to develop the collective will and take the social action necessary to enable them to protect their own health.
One way to do that is to improve the status of women. Empowering women has long been seen as an important public health goal.2 Where women are more educated and independent, societies tend to be much healthier than would otherwise be expected, at least partly because it is usually women who fight for better services and living conditions for their families. Unfortunately, there is no commonly accepted method for giving more power to women. A variety of programs, each with strengths and shortcomings, have been attempted, including press and radio campaigns to raise awareness of women’s rights issues; programs to increase the number of girls enrolled in school or the number of women in paid employment; and programs to improve the distribution and development of contraceptives and “microbicides”—as yet nonexistent vaginal gels that could, potentially, block HIV infection.
However, new research from South Africa suggests that it may be possible to dramatically change the status of women in a very short time, even in the poorest, most troubled communities, at relatively low cost. In 2001, a group of researchers (including one of us, Julia Kim) from South Africa’s University of the Witwatersrand School of Public Health and the London School of Hygiene and Tropical Medicine set out to study the impact of a “microfinance” program that offered small-business loans to African women living in impoverished rural villages in Limpopo, one of South Africa’s poorest provinces. Since the 1970s, similar microfinance programs have helped poor women in many developing countries from Bangladesh to Brazil gain a degree of independence by setting up small enterprises such as buying and selling food, clothes, or cosmetics. Foreign policy experts increasingly favor these programs because they recognize that gender inequality is not only an injustice in its own right, it also hinders economic and social development.
In agricultural societies, women perform most of the labor, but much of it is unpaid. Microfinance programs bring women into the cash economy, encourage the poor to develop entrepreneurial habits and skills, and sometimes help stimulate economic growth.3 In places like South Africa, these programs may also reawaken a spirit of ambition and purpose in communities long demoralized by lack of opportunities, apartheid-era forced relocations, discriminatory laws, and a culture of inequality that has numbed many poor people into dependency upon government welfare. While hardly a panacea for the myriad hardships faced by poor people in developing countries, microfinance programs have improved many women’s lives. Studies have suggested that microloan recipients tend to have fewer children than other women, and that the children they do have are healthier. Muhammad Yunus, the founder of Bangladesh’s Grameen Bank, a model for microcredit programs around the world, won the 2006 Nobel Peace Prize, and many organizations, including the US Agency for International Development, the Bill and Melinda Gates Foundation, and the World Bank, are expanding their microfinance programs or starting new ones.
The South African researchers wanted to see whether adding a series of “workshops” on gender issues to a microfinance program could give women more power and reduce the incidence of domestic violence and the spread of HIV in their community. In many societies, including South Africa, domestic violence—physical or sexual abuse by a husband or boyfriend—seems deeply entrenched in the local culture. Victims seldom call the police, neighbors rarely intervene, and even the police and courts don’t take cases of abuse of women seriously.4 Research linking domestic violence to the spread of HIV in Africa has drawn increased attention to this serious problem. According to several recent studies, abusive men tend to have more sexual partners, and are thus more likely to be HIV-positive, and abused women often have difficulty insisting on condom use or refusing sexual advances.5 According to the World Health Organization, one in three women worldwide has experienced domestic violence. Although it occurs everywhere, it is far more common in developing countries like South Africa, perhaps because gender relations are particularly vulnerable to the upheavals of social and economic change.6
In 2001, in collaboration with the Small Enterprise Foundation (SEF), a local microfinance organization, the South African researchers started a program known as IMAGE, or Intervention with Microfinance for AIDS and Gender Equity. Groups of about forty SEF participants were already meeting every two weeks to repay loans and discuss business plans; the IMAGE researchers expanded those meetings to include a series of “workshop” sessions addressing issues related to gender and HIV. The women were obliged to attend these workshops—called “Sisters for Life”—as a condition of receiving further loans. Each session was run by a woman from the local community who had been trained to lead open-ended discussions about sexuality, personal relationships, the different roles of men and women in daily life, and the effects of local culture on the treatment of women. The women would then act out before their peers the real-life domestic situations in which they found themselves and discuss them frankly.7
At first the women, especially the older ones, didn’t like the meetings. “We don’t feel comfortable talking about such issues. It is not our culture,” said one. In one session, they sang traditional wedding songs instructing new wives about how to behave toward their husbands. As the words of one popular song cautioned, “The road ahead will be rocky, but no matter what happens, you must stay with it.” This prompted a discussion about their personal experiences of being beaten by their husbands or boyfriends and of looking away in silence when their own daughters suffered the same fate. For many this was the first time they had shared such painful, personal stories without fear of ridicule or judgment. Deeper questions soon arose. Were the old ways good ways? Who decided what constituted “culture”? And was their own experience what they wanted for their daughters? Could it be that “culture” was not set permanently, but could change?
Indeed, it could. After two years, the women who had participated in the IMAGE program were half as likely to have experienced domestic violence in the previous year when they were compared to a similar group of women who had not participated in the program.8 The rates of divorce and separation of the participants did not increase; instead, women’s status and men’s perceptions of women changed. Women reported that their partners valued more highly their contributions to the household and treated them with more respect. They also reported a greater sense of self-confidence and improved communication with their partners about sex and HIV.
IMAGE’s success depended crucially on the collective social energy the program created by bringing the women together to solve common problems that none of them could solve on her own. It sounds simple, but in the field of public health this is actually a radical idea. Most public health interventions tend to address health problems on a case-by-case basis, by, for example, delivering drugs, vaccines, contraceptives, and other items to individual people or supplying individuals with information on which to base personal decisions concerning his or her health.
IMAGE, on the other hand, gave women a new language, and they used it to try to heal the ailments of their community. Soon they began to speak openly about women’s rights not only in workshop meetings and among themselves but in speeches before church congregations, school assemblies, and even a soccer club. Before joining the loan program, most of the women had known the humiliation of having to beg for food or money from their neighbors, and this discouraged them from speaking out against abuses. As one woman put it, in the past “they’d look at us and say, ‘your grandmother came from the poorest family in this village. What could you possibly have to teach us?'” Now both the income from their businesses and a shared commitment to the cause of women’s rights gave them the confidence to speak out together. “Women supporting women” became their slogan. In December 2003, they mobilized their neighbors to march in support of the international campaign against gender violence called “16 Days,”9 an event covered in their local paper.
Many microfinance programs, including IMAGE, work only with women. Program officials tend to favor women because they are more likely to repay loans than men are, and are also more likely to spend their earnings on household welfare. Some experts have argued that such projects must also include men if they are to have an impact on gender-based violence or AIDS,10 but the IMAGE researchers found that programs that help women can sometimes have an effect on men too. All women have men in their lives—men they work and live with and care about. With their new-found resources, knowledge, skills, and solidarity, the IMAGE women found the courage to enter traditionally male domains and collaborate with male community leaders including village chiefs, police, and school principals to raise awareness about domestic violence and HIV. When a girl in one village was raped and the police failed to respond, the women started a village rape committee to advise the police station about how to improve their services and accountability. Other women vowed to begin at home, by changing the way they raised their boys.11
Fewer than 15 percent of women in the IMAGE villages participated in the program of loans and workshops. Nevertheless, the researchers wanted to see how the program might affect the risk of HIV infection among young people in the community. The impact of the program among this group would have had to occur indirectly—it was hoped that the IMAGE women would pass on what they had learned to the young by means of education, changes in social norms, or participation in community activities. Although the researchers measured no effect on HIV incidence within three years, there were encouraging signs of change within participant households, including improved communication about sex and HIV between young people and their parents or guardians. It is reasonable to expect that by raising the status of women and reducing domestic violence, programs like IMAGE could have a powerful effect on the AIDS epidemic in the years to come, especially now that the South African government has pledged to place greater emphasis on HIV prevention.12 One of us (Helen Epstein) was in Uganda during the early 1990s, when the HIV infection rate there was falling steeply. An overlooked factor in this success was the presence of a powerful women’s rights movement, very similar to the one that is now emerging in the villages where the IMAGE program was carried out.13
Uganda’s women’s rights movement is one of the oldest in Africa, and it flourished in the politically liberal atmosphere allowed by the government in the late 1980s. For decades, the movement had been suppressed by the paranoid dictatorships of Idi Amin and Milton Obote, but in 1985, a small number of Ugandan women attended the UN Conference on Women in Nairobi, Kenya, and they returned with new energy and ideas. When the young coup leader Yoweri Museveni came to power in 1986, he promoted community organizing and self-help, which encouraged the women even more. Before long, at rallies throughout the country, women were being urged to keep their daughters in school, start small businesses, and challenge laws and practices that discriminated against women, either by restricting their property rights, failing to protect them from rape, or maintaining divorce laws that favored men.
HIV was always on the agenda. “There was not a single workshop or meeting where the subject of AIDS did not come up,” says Maxine Ankrah, who helped establish Action for Women in Development, Uganda’s largest women’s rights organization at the time. “We told women if your husband is unfaithful and is going to kill you with AIDS, you divorce him.”
This was also the implied message of the Ugandan government’s famous AIDS campaign, which urged people throughout the country, especially men, to change their sexual behavior. The slogans “Love Carefully” and “Zero Grazing”—meaning, in the words of the head of Uganda’s AIDS Control Program, “avoid indiscriminate and free-ranging sexual relations”14—were posted on public buildings, broadcast on radio, and repeated in speeches by government officials.15 There was even a Ugandan Association of Co-wives and Concubines that policed the behavior of polygamous men, to encourage them to avoid the casual affairs that could endanger all their wives and their future children. Meanwhile, the eloquent sadness of women throughout the country who nursed the sick and helped neighbors cope was a further harsh reproach to promiscuous men. So was their gossip, a highly effective method of spreading any public health message.
During the late 1980s and early 1990s, the fraction of Ugandan men with multiple partners sharply decreased, and as a result, the HIV infection rate fell by roughly 60 percent.16 At the same time, laws governing rape and women’s property rights were strengthened. The enrollment of girls in school rose swiftly, as did the participation of women in the economy.
Although abuses against women still occur in Uganda,17 they are less frequent than they are in South Africa, and gender-related attitudes have clearly shifted. For example, in the early 1980s, rape was generally considered an excusable crime in Uganda, and was even a laughing matter for some Kampala lawyers and officials.18 But then women’s rights activists began speaking out about the double horror of rape and AIDS. They organized marches against rape in the city streets and warned women across the country to band together and confront abusive men. In the early 1990s, Miria Matembe, a member of the Ugandan parliament, declared that “rapists, defilers and all those who in one way or another commit sexual offenses are in possession of potentially dangerous instruments which must be taken away from them if they can’t use them properly.” Although her remarks were not a statement of policy, they still seemed scandalous; but you don’t hear many jokes about rape in Uganda anymore.
Uganda’s widespread social mobilization against AIDS and gender violence touched every corner of society, from the president’s office to the remotest villages. But it started with frank, open discussions among friends, relatives, and neighbors, some of whom became the policymakers and activists who shaped the nation’s response to AIDS. AIDS experts increasingly recognize the power of ordinary discussions to spread new ideas, transform gender relations, and change sexual behavior.19 For example, Stepping Stones, a program of community workshops designed, like IMAGE, to improve communication among men and women and among youth and adults, was developed in Uganda ten years ago and has since been carried out in over one hundred countries. The South African Medical Research Council is now evaluating a South African Stepping Stones program to determine its effect on the incidence of domestic violence and HIV transmission. Results should be available in early 2007,20 but anecdotal reports of the program from Uganda suggest that it, like IMAGE, can lead to social change.
As one Ugandan who helped lead Stepping Stones workshops put it, “I have seen conservative, authoritarian men of the armed forces mellow down to pleasant smiling change agents within a period of only seven days in Stepping Stones training programmes. This is not solely the responsibility of the facilitators but also the dynamics within the peer group.”
“It’s kind of transforming attitudes,” said another workshop leader. “One thing I learnt, I’ve never listened to people. It made me realise I’m a bad listener. It helped me enormously to improve relationships between me and my son. We listen to each other a lot now.”21
So far, few international aid agencies have invested in programs to address the social and political obstacles to improving health in developing countries. Few support human rights groups, including women’s rights groups, or research into the links between health and human rights. Many of the agencies that fund microfinance programs have begun to put pressure on them to become “cost-effective” right away, cutting out additional services, such as health and nutrition education or HIV-prevention activities, even though combined programs almost certainly result in more powerful and lasting improvements in the well-being of poor families than financial services alone. The additional services may even pay off in the long run. A preliminary economic evaluation of the IMAGE study suggests that the workshops on women’s rights and HIV can be added with minimal additional cost to the program. There were even indications that loan centers that included the workshops had higher repayment rates and fewer dropouts than those that did not.22 Thus, while the new support for microfinance programs is welcome, donor agencies should bear in mind that changing the status of women—and reducing the spread of HIV—may also require something that money can’t buy: a new sense of confidence and solidarity among the poor and oppressed.
This is not a new idea in public health circles. In 1978, the World Health Organization and UNICEF sponsored a large-scale conference in Alma Ata, Kazakhstan, on public health in developing nations. Thousands of experts, including the health ministers of more than one hundred nations, came together to launch the “Health for All” movement, a global campaign to deliver basic health care to the world’s poor by the year 2000. The final declaration of the conference recognized that this would require not only increased funding for services and drugs but also greater popular participation. Poor people needed not just medicine but the confidence to join with one another to influence decisions about everything from the types of services they received to the social and economic conditions—including gender inequality—that placed them at risk of illness in the first place.
The Alma Ata Declaration was in many respects a fading gleam both of 1960s communitarian thinking about development and of the naive optimism that sometimes characterized it. By 1980, global recession, the debt crisis, and a new group of conservative leaders in the US and Europe lowered the curtain on the Alma Ata “Health for All” movement. It would soon be replaced by vertical, technocratic approaches to delivering health commodities such as vaccines, antibiotics, and contraceptives in developing countries. These programs saved many lives, but recently, as infant and maternal mortality rates in some countries have ceased to fall or even risen23—a trend not attributable entirely to the AIDS epidemic—some experts have begun to ask whether the political, communitarian element may not be crucial for sustaining such gains. In the absence of concrete support for the complex human process of engaging with and mobilizing communities, the new philanthropists may find that the lofty goals they have set themselves will be beyond their reach.
Perhaps recognizing this fact, a high-level panel of government, UN, and nongovernmental organization officials recently urged the UN to create a new agency to advance the rights of women throughout the world. This agency would sponsor research and conferences and give grants to local women’s empowerment projects. The officials of such an agency would do well to learn the concrete lessons of programs like IMAGE and to apply them pragmatically. But global agencies must also recognize that although microfinance programs can provide an economic foothold for some poor people, in an increasingly globalized economy it is naive to assume that such programs on their own could ever significantly close the vast gulf between rich and poor that continues to strain millions of poor families and to exacerbate the twin scourges of domestic violence and HIV. Nor could changing the economic policies of any one nation-state.
As long as rich governments continue to contest—as they did at the most recent G8 Summit and the Doha round of World Trade Organization talks—more sweeping policy changes, such as scrapping their own agricultural subsidies or making the terms of trade fairer in other ways, their programs to build schools, distribute AIDS treatment, and even provide microfinance should be seen as disaster relief measures, and not as long-term solutions to the problem of poverty in the developing world.
A first step would be to revive the notion that public health is intrinsically political, and that foreign aid should not be just a transaction between donors and recipients, but a collaboration addressing common problems. As the writer and educator Paolo Freire wrote a long time ago, “The elite defend a sui generis democracy in which the people are ‘unwell’ and require ‘medicine’—whereas in fact their ‘ailment’ is the wish to speak up and participate.”24 Poor people do have the power and ability to help themselves, but they can’t do it alone.
February 15, 2007
For recent discussions of this movement, see Perspectives on Health and Human Rights, edited by Sofia Grus-kin (Routledge, 2005); Paul Farmer, Pathologies of Power: Health, Human Rights, and the New War on the Poor (University of California Press, 2003); the Web site of the Global Coalition on Women and AIDS and its many nongovernmental agency partners (womenandaids.unaids.org); and the Global AIDS Alliance, “Zero Tolerance: Stop the Violence Against Women and Children, Stop HIV/AIDS,” August 1, 2006 (www.globalaidsalliance.org). ↩
See the United Nations Millennium Declaration, General Assembly resolution 55/2, September 8, 2000 (www .ohchr.org/english/law/millennium.htm); J. Caldwell and P. McDonald, “Influence of Maternal Education on Infant and Child Mortality: Levels and Causes,” Health Policy and Education, Vol. 2 (1982), pp. 251–267. ↩
See L. Mayoux, Beyond Rhetoric: Women’s Empowerment and Micro-enterprise Development (Zed, 2001). ↩
See Charlene Smith, Proud of Me: Speaking Out Against Sexual Violence and HIV (Penguin, 2002). ↩
See K.L. Dunkle et al., “Perpetration of Partner Violence and HIV Risk Behaviour Among Young Men in the Rural Eastern Cape, South Africa,” AIDS, Vol. 20, No. 16 (October 24, 2006), pp. 2107–2114; and R. Jewkes et al., “Factors Associated with HIV Sero-status in Young Rural South African Women: Connections Between Intimate Partner Violence and HIV,” available at the Web site of the International Journal of Epidemiology at ije.oxfordjournals.org/cgi/content/abstract/ dyl218v1. ↩
See Claudia Garcia-Moreno et al., “Prevalence of Intimate Partner Violence: Findings from the WHO Multi-country Study on Women’s Health and Domestic Violence,” The Lancet, Vol. 368, No. 9543 (October 7, 2006), pp. 1260–1269. ↩
For details of the program’s implementation, see P.M. Pronyk et al., “Integrating Microfinance and HIV Prevention-perspectives and Emerging Lessons from Rural South Africa,” Small Enterprise Development, Vol. 16, No. 3 (September 2005), pp. 26–38; and www.wits.ac.za/health/publichealth/radar. ↩
P.M. Pronyk et al., “Effect of a Structural Intervention for the Prevention of Intimate Partner Violence and HIV in Rural South Africa: Results of a Cluster Randomized Trial,” The Lancet, Vol. 368, No. 9551 (December 2, 2006), pp. 1973–1983. ↩
The 16 Days campaign—which chose sixteen days each year to call attention to violence against women—is organized by the US-based Center for Women’s Global Leadership (www.cwgl.rutgers.edu/16 days/home.html). ↩
See “Engaging Men in Gender Equity and HIV/AIDS,” a session at the 16th International AIDS Conference, Toronto, Canada, August 2006. ↩
For details on how women and communities responded to the IMAGE program, see Julia C. Kim et al., “Understanding the Impact of a Microfinance- Based Intervention on Women’s Empowerment and the Reduction of Intimate Partner Violence in the IMAGE Study, South Africa,” American Journal of Public Health (forthcoming, 2007). ↩
See “Stop AIDS—Keep the Promise,” address delivered by the deputy president, Ms. Phumzile Mlambo-Ngcuka, at the World AIDS Day event, KaNyamazane, Nelspruit, Mpumalanga, December 1, 2006. ↩
See Aili Mari Tripp, Women and Politics in Uganda (University of Wisconsin Press, 2000); Miria Matembe, Gender, Politics and Constitution-making in Uganda (Kampala: Fountain, 2002); The Women’s Movement in Uganda: History, Challenges and Prospects, edited by Aili Mari Tripp and Joy Kwesiga (Kampala: Fountain, 2002); and Sylvia Tamale, When Hens Begin to Crow: Gender and Parliamentary Politics in Uganda (Kampala: Fountain, 1999). ↩
See “AIDS War Begins,” New Vision (Uganda), October 3, 1986. ↩
See Helen Epstein, “God and the Fight Against AIDS,” The New York Review, April 28, 2005; and Helen Epstein, The Invisible Cure: Africa, the West, and the Fight Against AIDS,to be published by Farrar, Straus and Giroux in May 2007. ↩
Rand L. Stoneburner and Daniel Low-Beer, “Population-Level HIV Declines and Behavioral Risk Avoidance in Uganda,” Science, Vol. 304, No. 5671 (April 30, 2004), pp. 714–718. ↩
See, for example, “Just Die Quietly: Domestic Violence and Women’s Vulnerability to HIV in Uganda,” Human Rights Watch, August 2003; but for a comparison of domestic battery rates in Uganda and South Africa, see Michael Koenig et al., “Domestic Violence in Rural Uganda: Evidence from a Community-Based Study,” Bulletin of the World Health Organization, Vol. 81, No. 1 (2003), pp. 53–60, and Kristin Dunkle et al., “Prevalence and Patterns of Gender-Based Violence and Revictimization among Women Attending Antenatal Clinics in Soweto, South Africa,” American Journal of Epidemiology, Vol. 160, No. 3 (August 1, 2004), pp. 230–239. ↩
See Aili Mari Tripp, Women and Politics in Uganda. ↩
See Daniel Low-Beer and Rand L. Stoneburner, “AIDS Communications Through Social Networks: Catalyst for Behaviour Changes in Uganda,” African Journal of AIDS Research, Vol. 3, No. 1 (2004). ↩
See R. Jewkes et al., “A Cluster Randomized-Controlled Trial to Determine the Effectiveness of Stepping Stones in Preventing HIV Infections and Promoting Safer Sexual Behaviour amongst Youth in the Rural Eastern Cape, South Africa: Trial Design, Methods and Baseline Findings,” Tropical Medicine and International Health, Vol. 11, No. 1 (January 2006), pp. 3–16. ↩
Quotes taken from the Stepping Stones Web site, www.steppingstonesfeedback.org/ref.htm#refquotes. ↩
A full economic evaluation of the IMAGE project is currently being carried out by the London School of Hygiene and Tropical Medicine, the London School of Economics, and the George Institute for International Health. ↩
See Neff Walker et al., “Meeting International Goals in Child Survival and HIV/AIDS,” The Lancet,Vol. 360, No. 9329 (July 27, 2002), pp. 284–289. See also Helen Epstein, “Claiming the Right to Health,” The Lancet, Vol. 366, No. 9492 (October 1, 2005), pp. 1155–1156. ↩
Paolo Freire, Education for Critical Consciousness (Continuum, 2002). ↩