Marion: The State of the Nation speech happened last week and despite a number of health challenges continuing to face South Africans, far less was said about this than would have been the ideal. In fact, more was said about the Rhino protection programme.
Within health the broad epidemics of HIV, Tuberculosis (TB), Violence against women (VAW) and substance abuse were noted and plans to remedy these through antiretroviral Treatment (ART) and TB treatment programmes, speaking out against VAW and tobacco control were proposed.
As I was digesting this input the face of a black woman with a bruised face surfaced repeatedly on my media platforms, following her expulsion from the House in the EFF scuffle. This disconnect was jarring.
In my area of focus (reproductive justice) women, and in particular black women, continue to bear the brunt of ill health in South Africa. We need leadership and the implementation of our good policies in order to truly transform the lives of women accessing reproductive health services. Schools need to provide comprehensive sexuality education and provide condom access (both female and male). We also need to continue Human Papilloma Virus (HPV) vaccination programmes to reduce the risk that women will contract cervical cancer late in life.
Women and girls need information about the range of contraception options available and to be able to have a conversation with a health provider and choose the method that is most suitable for them. Should contraception fail and a pregnancy takes place women should have access to HIV testing and also have access to a safe and legal abortion and not have to have to resort to an illegal provider. Maternal health programmes need to continue to welcome women and to provide them with good information about their pregnancy and planned delivery.
The Department of Health needs to strengthen it’s work on sexual and reproductive health and rights and the leadership needs to refrain from using misinformed language that suggests that women use abortion as a form of contraception. Commodities, supplies in relation to reproductive health from female condoms to IUCDS need to be strengthened. These suggestions are not new, our Department of Health has fabulous policies, but little leadership and stewardship to implement them.
Are Rhino’s more important than the health of women in South Africa?
Rebecca: There is good news and bad news.
The good news:
By the end of 2010, over 1 million people in South Africa had been initiated on ART (Republic of South Africa 2010). By 2013, this figure had escalated to 2 010 340 adults reported to be receiving ART in South Africa’s public health services (UNAIDS 2013: A86). The expansion in ART provision was testament to the efficacy of a broad-based alliance of healthcare workers, patients, activists, researchers, government officials, donors and other partners who continue to collaborate in the expansion and improvement of the national HIV response. South Africa’s ART programme has begun to reverse the precipitous decline in life expectancy, wrought by AIDS mortality, that came to characterise South African demography in the late 1990s. Due to the provision of ART, life expectancy in South Africa has increased by six years, and mortality among children and adults has declined by 43% and 20% respectively (Mayosi et al, 2012). By 2010, the life expectancy of patients initiating ART was around 80% of normal life expectancy (Johnson et al. 2013: 5).
The bad news:
The structural factors that increase vulnerability to HIV infection and transmission pose persistent challenges to the progress in South Africa’s health sector, and to the democratic transition more broadly. These factors are manifest in enablers of HIV infection, including unemployment, alcohol abuse and gender violence. While health and social interventions to diagnose, treat and manage HIV have provided some of the services necessary to address the needs of patients, the deep-seated determinants of risk and resilience towards HIV infection in South Africa have remained largely intact.
In South Africa’s struggle for public access to treatment, the attention of health care workers and activists was focused on initiating patients onto antiretroviral treatment. Now that South Africa has the world’s largest cohort of patients on antiretrovirals, we must confront the challenges posed by sustaining a massive public health intervention at a time in which resources for health are declining and there is donor fatigue for funding HIV treatment programmes (Mills et al., 2010).
The stigma surrounding HIV remains prohibitive, preventing the vast majority of HIV-positive people from disclosing their status openly and publicly. While antiretroviral treatment has saved the lives of many, recent studies have shown that, contrary to the expectations of public health specialists, the public provision of treatment has not alleviated HIV stigma in South Africa.
While the fight for public access to ART has won numerous gains for women, the primary focus on their health outcomes as mothers, and the related prioritisation by public health specialists, donors and activists of Prevention of Mother To Child Transmission (PMTCT) initiatives, has shifted attention away from other reproductive health rights. Health interventions that have prioritised treatment for women as mothers has placed primary value on their reproductive capacity rather than their individual health outcomes (Eyakuze, Jones, Starrs & Sorkin, 2008, p. 33).
In spite of the requirement in many healthcare settings that HIV-positve women accept contraception as a pre-requisite for access to ART, social sanctions and individual factors compelling people to become parents continue to play a formative role in the reproductive choices of people with HIV. If the roll-out of ART is to continue to improve the health outcomes of women in Southern Africa, sexual and reproductive health must be repositioned at the centre of HIV prevention and treatment programmes.
South Africa has among the highest rates of rape and sexual assault in the world, but research has shown that very few women report rape or seek healthcare services after being raped or assaulted.[i] Survivors of rape and sexual assault have the right to free medical advice and medications, as stated in the Sexual Offences Act (2007).
Jen: In terms of mentioning women specifically, the 2015 SONA limited itself to describing the fact that ‘some progress had been made in fighting crimes against women and children.’ Whilst that can be debated in other platforms, what is important to consider for women’s health is the very strong linkages between violence against women and HIV and sexually transmitted infection contraction.
In addition to what Rebecca describes above, the links between violence and HIV have been well documented by the World Health Organisation and can be summarised as follows:
- rape and sexual violence usually result in trauma to women’s genitalia, increasing the likelihood of contracting HIV and other viruses;
- sexual abuse in childhood has been linked to risky sexual behaviour in adulthood, increasing the chances that an individual will contract HIV;
- violence or fear of violence can reduce the likelihood that a woman feels safe or empowered to negotiate condom use;
- violence or fear of violence, in addition to societal stigma and the gendering of disease, can make it less likely for women to go for HIV and other STD testing; and
- violence can make it less likely for women to go for antenatal testing when pregnant, thus reducing the efficacy and reach of programmes designed to prevent mother to child transmission.
Sonke Gender Justice recently called for a National Strategic Plan on violence against women, and this is a call that bears serious consideration.
Another element that was left out of the State of the Nation was South Africa’s extremely high maternal mortality rate, and the fact that over the past years this has only reduced marginally. South Africa is far off from achieving the maternal mortality rate set by the Millennium Development Goals as made clear in Part 1 of this series. The leading causes of death were non-pregnancy related infection (most often HIV related illnesses) and high blood pressure. It seems essential then that the outreach of maternal health services should be widely expanded.
Our teen pregnancy rates also remain high. Early pregnancy has long term impacts on the lives of girls, and because of patriarchal gender norms continues to impact on girls education and life choices far more than it does on boys. In addition, the number of pregnancies that happen in school should be a serious concern as many of these are legally rape. Where healthy consensual sexual activity happens between adolescents, problems with the legislation around sexual offences have the impact of limiting adolescents access to sexual and reproductive health services, making it more likely that they will not seek treatment for sexually transmitted infections or pregnancy. Possible amendments to this legislation are currently before the Portfolio Committee on Justice. This must be addressed as soon as possible.
The State of the Nation will never be the speech that will solve all women’s health problems. However, there was certainly more space available to address these significant challenges than was used.