Differentials considerations for the caribbean


III. NO MARGIN OF SAFETY? WOMEN’S GENDER-SPECIFIC DIFFERENTIALS



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III. NO MARGIN OF SAFETY? WOMEN’S GENDER-SPECIFIC DIFFERENTIALS

“In any culture, people can assume to have a hierarchy of expectations which may be subjected to change in the face of crisis. The highest expectations include self-respect, a sense of worth, and the giving and receiving of affection. Other expectations may be an acceptable standard of living now and in the future. But all these expectations of life are acutely threatened by AIDS. Expectations about relationships with children and grand children have all been profoundly disturbed.” (Katahoire 1993:19).


Overall globally, the HIV incidence rate (the annual number of new HIV infections as a proportion of previously uninfected persons) is believed to have peaked in the 1990s and to have stabilized subsequently, notwithstanding increasing incidence in a number of countries. UNAIDS 2006 reports that there have been changes in incidence along with rising AIDS mortality that have caused the global HIV prevalence to level off due to changes in behavior and prevention programs. While these favorable trends may be encouraging at first flush, the numbers of people living with HIV have continued to rise due to population growth and life-prolonging antiretroviral therapy.40/
Data shows another pattern that points to a “feminization” of HIV infection. Internationally there has been a changing pattern in rates of male/female HIV infections. Long gone is the focus on homosexual transmission of the virus. The contours of patterns have changed; indeed, as the epidemic has spread there has been a progressive shift towards heterosexual transmission and increasing infection rates in women. By way of example, a 2004 review of HIV-infection levels among 15-24 year olds which compared the ratio of young women to young men living with HIV found that in South Africa twice as many women and men had the virus while in Kenya and Mali the ratio of HIV-positive young women to young men was 4.5 to 1.41/ According to the UNAIDS 2006 report, new survey data underscore the disproportionate impact of AIDS epidemic on women, especially in sub-Saharan Africa where, on average, three women are HIV-infected for every two men. Among young people, (15-24 years), that ratio widens significantly, to three young women for every young man.42/
In Sub-Saharan Africa 57 percent of adults living with the HIV virus are women, and two thirds of young HIV-positive people are women and girls. The worldwide proportion of women living with HIV/AIDS is almost 50 per cent.43/ Globally, young women are almost 1.6 times more likely to be living with HIV/AIDS than young men.44/ Worldwide, in 2003 there were an estimated 16, 300,000 women (15+) living with AIDS. In 2005, this figure jumped to 17, 300,000.45/
These high figures for women highlight the fact that women face gender-specific risks in a number of ways that make them more susceptible. The growing proportion of women affected by HIV arises from a mix of physiological, social and human rights factors, some of which have already been mentioned earlier. Women and girls appear to have a higher inherent risk of being infected via heterosexual activity (compared to men) because semen contains higher levels of HIV than vaginal fluids. Moreover the vagina offers a larger area of mucosal tissue subject to micro-injuries through which the virus can enter the bloodstream.
Women’s susceptibility and subsequent vulnerability are increased because of the delicate nature of the vaginal wall which is prone to abrasions and sores which act as an entry point for the virus. The risk of transmission is therefore increased if a woman has a sore, a vaginal infection or an STD (sexually transmitted disease). Added to this is the fact that it is more difficult for women to detect vaginal infections or sores, whereas because of the anatomy of males, such symptoms are more clearly and easily detected. Many women therefore participate in sexual activities in ignorance of the fact that they are afflicted by illnesses which threaten their reproductive health and the long incubation period of the HIV virus is a major contributory factor to the rapid spread of infection.46/
However, the differential levels of infection reported in southern Africa and elsewhere, where four to five times more young women than young men in the same age group are infected each year, do not reflect solely or even mainly biological differences between males and females, but rather social and human rights risk factors. Perhaps one of the most poignant examples of a reduced margin of safety is in women’s powerlessness and the dynamics surrounding the use of condoms.
In the Caribbean, as in many other parts of the world, it is the male partner who is perceived and who in fact, has and takes the prerogative when it comes to condom use. His cooperation is often difficult to obtain. Although condoms have been an important part of family planning programs used primarily to prevent pregnancy, they have also been a reliable method in preventing STDs. In addition to keeping out sperm, they also keep out germs and as such condom used has historically been stigmatized and often associated with illicit sexual activity. Because of this negative association with condoms it becomes difficult for women to “negotiate” more “risk free” sexual encounters or relationships. Thus, women are by social construct, more susceptible and may suffer increased vulnerability after infection and diagnosis with HIV/AIDS. In sum, in the Caribbean it is the construction of gender roles and the socialization process of females47/ that is partly responsible for women’s vulnerability and exposure to HIV infection.
The initial biological effect on women is also noteworthy as an indicator of reduced margin of safety to vulnerability. HIV/AIDS and its manifestations in women are experienced differently. For example, thrush in the mouth is more common in a first AIDS-defining condition in women than in men. Changes in menstrual patterns of many women diagnosed with HIV have also been reported. In addition it has been found that pelvic inflammatory disease (PID) and cervical cancer occur more severely in women with HIV.48/
One last example of vulnerability, for which the cost is at best difficult to tabulate because of its emotional content, has to do with stigma, discrimination and social ostracism. There is very little if any quantitative data on this aspect of vulnerability in the Caribbean against women or girls. There are however, heart-rending accounts of the situation by many women.49/ The experience of self stigma and loss of self-esteem was recounted by a Caribbean woman who, upon diagnosis of HIV/AIDS, said she had the feeling of “immanent death” and utter shock that this happened to her despite her monogamous relationship. She describes her depression and ostracism by the community that was accentuated by the loss of her job.
According to Dr. George Alleyne, “I doubt that this is an isolated example, and the fact that many women are so afraid of the stigma that they will not disclose their HIV status.”50/
The concept of differential susceptibility helps us understand the course of the epidemic through the circumstances or environments in which the disease may be transmitted. Notwithstanding the estimated 300,000 people living with HIV/AIDS at the end of 2005,51/ in the Caribbean large numbers of people continue to be infected, continue to fall ill and continue to die. As underscored earlier, these events do not happen in exactly the same way as not all people or communities are susceptible to infection in the same way or to the same extent, nor will all be affected in the same way or to the same degree.
There is also differential vulnerability to the impact of the disease. For example, it used to be that vulnerability of individuals, once infected, was not very variable. People could expect to experience the onset of disease, experience episodes of ill health that would increase in frequency, severity and duration until their demise. At best the wealthy could buy time with better diets and better palliative care. With the advent of anti-retroviral drugs those who have sufficient financial resources or who live at the mercy of helpful public policy can still “buy” extra days of life or have access to medical and social networks that mitigate vulnerability of the disease.
Susceptibility and vulnerability feed epidemics which are cataclysmic history-changing events. They terminate some lives, incapacitate others and stunt the capabilities of those who have to divert energy and time to deal with their effects. In the end, sufficient numbers of deaths and illnesses make individuals, communities and whole societies take a path that hitherto would not have been taken. This is impact: change by virtue of a series of events. Impact can be thought about as a continuum between a sharp shock and slow and profound changes, such as those caused by HIV/AIDS.
IV. UNDERSTANDING ECONOMIC IMPACTS

“....the Aids pandemic confronts us with a full range of development issues...issues of poverty, entitlement and access to food, medical care and income, the relationships between men and women, the relative abilities of states to provide security and services for their people, the relations between the rich and the poor within society and between rich and poor societies, the viability of different forms of rural population, the survival strategies of different types of household and community, all impinge upon a consideration of the ways in which an epidemic such as this affects societies and economies” (Barnett and Blaikie 1992:5).
DEMOGRAPHIC EFFECT: AN INITIAL IMPACT
The most glaring effect of AIDS as it relates to future economic concerns is a demographic one: the sheer impact on population. That is because one of the most measurable impacts of AIDS is on mortality rates: the rate at which people die and thus, can no longer participate in their economies. Increased mortality means the economy is left with fewer workers, both in total and across different occupations and skill levels. While the impact is very uneven across individuals or households, it can be said that the AIDS epidemic increases morbidity (sickness) and mortality (death) in populations at precisely those ages where normal levels of morbidity and mortality are low. Adults and many infants and children are dying prematurely.52/ For example, in 2004, 3 million persons died prematurely from AIDS; over 20 million have died since the first cases of AIDS were identified in 1981.53/

In most developing countries, particularly those in Sub-Saharan Africa, the highest infected region in the world, the drug therapy that can nowadays delay the life-threatening symptoms of AIDS is still largely inaccessible. Consequently, in 2000-2005, the 38 heavily affected countries in Africa were expected to experience nearly 15 million more deaths than they would have in the absence of AIDS. A further 3.5 million excess deaths were projected to occur in Asia, with India accounting for most of them. In Latin America and the Caribbean, the number of excess deaths was projected to be lower, amounting to 0.7 million, and in the two more developed countries with the largest number of infections --- the United States of America and the Russian Federation --- 0.8 million were expected.54/
In literature published by the University of the West Indies press in 2000, AIDS deaths would be expected to reach 1,753 by that year, for a rate of 278 per 100,000, in the Caribbean, or 2.4 times the death rate of heart disease in the region. Of these 1,753 deaths, 1,211 or 69 per cent would be in the age range 20-44. Once again, rates would be huge for women in the 25-49 bracket or 740 for 100,000 population, and for males in the 30-34 years bracket or 588 for 100,000 population. For females this rate would be 7.3 times the death rate from all other causes.55/
In the Caribbean, according to the Director of the Caribbean Epidemiology Centre, AIDS is the leading cause of death for people aged 15-45 and the number of cases is doubling every two or three years.56/ Understanding that the AIDS fatality rate is high, it is estimated the between 21,000 and 24,500 AIDS cases have died in CAREC member countries since the inception of the epidemic. Impact of the AIDS epidemic is very serious with 50 people dying of AIDS every month in Jamaica since 2001 and close to 5,000 people having died in Trinidad and Tobago since 1983 when the first cases were reported. As reported in 2004, AIDS has killed 3,123 people in the Bahamas and has impacted negatively on life expectancy in Guyana and elsewhere in the Caribbean region.57/ Simply put: AIDS leads to less life. As a result, AIDS drastically alters life expectancy and in so doing, alters participation in the cycle of economic participation.58/
Table 3 below shows life expectancy at birth, overall years of life expectancy lost (YLEL) and lost due to AIDS in selected income level and distribution gap country clusters of the Caribbean region, covering 1990-2002 period.
Table 3
Life expectancy at birth, overall years of life expectancy lost (YLEL) and lost
due to AIDS in selected income level and distribution gap country clusters of
the Caribbean region, covering 1990-2002 period


Country Cluster

Period

Life expectancy at
Birth

Years of Life
expectancy lost

Total YLEL due to
AIDS

Low income, narrow gap













Belize

1998-2000

68.2

16.81

0.70

Cuba

1999-2001

76.0

9.0

0.04

Guyana

1994-1 996

66.8

18.2

0.86

St Lucia

1993-1 995

70.3

14.7

0.02

St. Vincent and the Grenadines

1997-1999

69.0

16.0

1.32

Low income, wide gap













Haiti

1997, 1999

57.3

27.7

1.67

High income, narrow gap













Bahamas

1997,1999,2000

73.3

11.7

2.80

Barbados

1993-1995

73.7

11.3

1.12

Dominican Republic

1996-1998

70.9

14.1

0.46

Grenada

1994-1 996

73.0

12.0

0.35

St. Kitts &Nevis

1994, 1995

69.3

15.7

0.60

Trinidad & Tobago

1 994,’95,’98

70.0

15.0

0.76

High Income, wide gap













Brazil

1998-2000

67.9

17.1

0.25

Source: Pan American Health Organization. Mortality and Population Database. Technical Information System, 2002.
It is from these profound history-changing events that we understand the magnitude of the AIDS epidemic. It is from the magnitude of these unusual events ---high levels of morbidity and unusually high levels of mortality --- that other impacts flow, including economic ones. Impacts are also differential in nature. They may be felt as an immediate and severe shock or they may be more complex, gradual and long-term in the changes they bring about. In some situations, for example, knowledge of a seropositive status, AIDS illness and ultimate death may threaten to overwhelm the affected individual and other related individuals, whole communities and entire societies. Psychological damage as well as the inevitable physical damage accompanies the HIV/AIDS cycle. Some other individuals and institutional units may absorb the shock of slow erosion. Impact will occur and be coped with in different ways, under different circumstances and at different levels: household, community, or nation.
Table 4a and 4b provide a conceptual matrix for thinking about impact by level, time and degree. The difference in the level of impact is noted in the ‘institutional’ unit of analysis; the difference in time has to do with the phase or “wave” of the epidemic and differences in the degree of impact will reflect differential resource endowments.59/
Table 4a

Depicting impact by level, time and degree


Level of Impact Time of Impact Degree of Impact Does evidence exist

This happens?
Individual Early Always severe and Yes – death and illness

Variation by gender and age


Household Early Severe emotional, variable Yes, household studies in

Financial depending on socio- the literature. Orphans

Economic status, gender, ethni- and elderly particularly

city, and other social variables affected


Community Early, middle and late Variable: dependent on scale, and Yes, Orphans, elderly

Resource base of community but likely and service provision

To be long term and profound but not affected
Necessarily easy to see

Table 4b

Depicting impact by level, time and degree
Level of Impact Time of Impact Degree of Impact Does evidence exist

This happens?

Production Unit/ Middle and late Variable: dependent on the nature of Yes, large organizations

Institution an organization or institution’s activities are affected by additional

Or type of production and labor mix costs


Sector Late Variable: dependent on location, pro- Yes, rural livelihoods and

duction and use of labor agriculture are affected


Nation Late Economic probably slight, other No, only economic models

May be great. At present no evidence and anecdotal evidence



about effects on govern- ment infrastructure

Source: Barnett and Whiteside, p.173.



The differential impact of AIDS is seen in its relationship to poverty and poverty-stricken people. Living standards of poor people were being whittled down before the impact of AIDS was felt, and the worst hit countries today are not necessarily the poorest countries. Southern Africa, with the world’s highest HIV prevalence of over 20%, includes the most economically developed countries in sub-Saharan Africa. Poor people in relatively high income countries represent pockets of poverty in the midst of relative wealth. AIDS tends to affect the poor more heavily than other population groups because their ability to cope is less robust given their asset-poor condition and their dearth of necessary safety-nets. In Botswana, for example, every income earner is likely to acquire one additional dependent over the next 10 years due to the epidemic. But families in the poorest quintile will acquire an additional eight people who will become dependent on their income as a result of AIDS (Greener, 2004).60/ People who are economically disenfranchised are particularly buffeted by the disease.
As a category, women and their economic situation highlight the differential impact AIDS may have. While women are not economically disenfranchised in the absolute anywhere in the world, the rates of unemployment of women in the formal economy are generally lower than for men, since they are often engaged in subsistence farming as well as in their domestic and reproductive roles.61/ In the Caribbean, women are twice as likely as men to be unemployed. Their difficulty in securing paid work makes them dependent on men, the state and kin to help make ends meet under daily living conditions.62/ Faced with unemployment and/or difficult access to formal employment, women in the Caribbean, especially female household heads, are less likely to have safety-nets and thus, suffer increased impact by the monetary cost of AIDS than most men, who when employed, are buttressed by some measure of reduced economic stress and increased ability to initially cope with certain economic aspects of AIDS.
Becoming seropositive may have a disproportionate economic impact on women compared with men since when employed, women are more likely to lose employment in the formal sector than men. In fact, self-employment can have positive advantages in resilience for women who become infected and suffer social ostracism and possible expulsion from their homes. When women are already the main breadwinner or are forced to become the main breadwinner because their partner has become infected, women lacking education and marketable skills may take the decision to enter into hazardous occupations, including sex work, that not only increases their susceptibility but also thereafter, increases vulnerability in a vicious cycle of disease.


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