Issues Paper No. 6

PLACING WOMEN AT THE CENTRE OF THE ANALYSIS
Elizabeth Reid

Acknowledgements
Biographical Note

There is a growing consensus in the development assistance world that human development should provide the framework for development assistance in the 1990s. Yet, while this is widely welcomed by women, there are few, if any, grounds for assuming that this ideology will benefit women any more than any of the previous development assistance ideologies, be they economic growth, growth with equity, basic needs or whatsoever.

 The literature on women and development extends back almost as far as the literature on development itself. The mandates and directives have long been in place. Yet, the success stories are anecdotal rather than systemic and this is causing a growing questioning of past approaches.

 There are those amongst us, serious but with a sense of humour, who, in response to this chronic failure, are now proposing two new but linked approaches: the radical procedural approach and the radical analytical approach. The first approach consists in developing a set of procedures that might better bring about the achievement of our women in development objectives. For example, all missions that are responsible for programme or project formulation, implementation teams and evaluation missions must be predominantly or exclusively composed of women. All hose consulted during such missions must be predominantly or exclusively women, and so on. Such procedural directives, if issued by UNDP or CIDA, for example, would undoubtedly be greeted by great discomfiture if not outrage. But it is interesting to note that the obverse, which is the present situation, is not.

 The radical analytical approach places women at the centre of the analysis; that is, in any development-related activity whatsoever, the analysis should begin at where women are, whatever they are doing, and should aim to get them (women) where they want to be and bring about the changes they want. the rest of the world (men, children, social institutions, financial institutions, economies, etc.) are to be drawn into the analysis primarily on the basis of how they relate to women or how they can contribute to achieving women's goals. Again, radical only in that the obverse is the accepted modus operandi.

 Today is not the occasion to elaborate on these approaches, but it is the occasion to understand the cost if we do not place women at the centre of the HIV analysis. The failure to do so has already brought an immense cost in women's lives, a cost which is forcing an understanding that, for the 1990s and beyond, human development will be conditional upon human survival; that is, human survival, not human development, may well become the primary focus of our development assistance.

 Let me elaborate on this, taking the example of HIV/AIDS. The main focus of HIV/AIDS programmes to date has been the prevention of the further transmission of the virus. I will focus on sexual transmission since, for women, this is the overwhelming way in which women become infected.

 The three main prevention strategies for sexual transmission that are being advocated, particularly in developing countries, are: one, the reduction of the number of sexual partners; two, condom usage; and three, faithfulness in relationships and celibacy and abstinence outside of them. To these, a fourth has recently been added, namely, the treatment of STDs.

 I do not wish to discuss, today, the merits of these strategies, per se, bur rather to look at their adequacy as prevention strategies for women and those who people women's world.

 Let's take the first, reduction of sexual partners. Preliminary data from African studies indicate that 60% to 80% of all infected women have one and only one sexual partner. Therefore, this strategy has no relevance to their lives. Nor is it relevant to the lives of those women who, because of economic circumstances, are forced to sell or exchange sexual intercourse. Thus, for the majority of women this strategy is inapplicable, irrelevant strategy.

 Secondly, condom usage. Men use condoms. Results from programmes with sex workers have clearly shown that some women can successfully negotiate condom use. However, this remains a rare skill among women. Most men do not use condoms, and most women do not have the ability or the leverage to protect themselves in this way. This is a strategy for men.

 Thirdly, faithfulness, abstinence and celibacy. At the current stage of the epidemic, it can be estimated that every day, each day now, 1,500 faithful women are infected. That is, every day, just now, there are 1,6500 women who have no sexual partners other than their husbands who are becoming infected. This number will increase as the number of infected men increases. There are some indications that the incidence of rape, particularly of young girls, has increased and there is no reason to believe, in fact, on the contrary, that this is not also true of incest. For most women, abstinence and the faithfulness of both partners in a relationship is not within their power to bring about. For a growing number of girls and women, sexual assault is a reality. So this strategy is inapplicable.

 These are grim facts. But they are the realities that lie hidden behind the epidemiological data. The strategies that are being advocated are strategies that men, now women, have under their control. This is the area why one in every 40 adult women in Africa is infected. It is the reason why there are as many or more women in Africa that men as infected. It is also the reason why, in the Latin American and Caribbean regions, the male/female infection ratio has dropped so precipitously over the last couple of years.

 Is there no hope for women? In the longer term, the power imbalances in relationships and society which create women's subordination must be changed. But what, in the short term, can women to do save their lives and those of their children?

 If one lays aside for the moment the current strategies and begins the analysis with the reality of women's lives, then the first question is: Is there any protective measure that a woman has under her own control which will offer her protection from infection?

 Protective measures can be divided into two types: those which prevent contact with an infected person and transmission of the virus and those that decrease the efficacy of transmission when unprotected sexual contact occurs. The first, for example, includes condom usage, faithfulness and abstinence. Then measures are much more efficacious than the second type. However, the second type may overall be just as effective, or more effective, if more people can act upon them.

 There are, in fact, in each of these two categories, some measures that an individual woman can use. It is important that we start naming them.

 One of the most efficient know means of reducing the efficacy of transmission of the virus, that is, when you have unprotected sexual intercourse with an infected person, is unbroken genital skin. This is the advice we give to health workers: The most effective barrier is unbroken skin. If you are covered in blood, wash it off. In the genital area, unbroken skin is also protective.

 Transmission of the virus can be facilitate by the presence of genital lesions, inflammation, secretions and scarification. The causes of these conditions in women include genital urinary tract infections, STDs, sexual practices and traditional infibulation practices. All genital conditions which may facilitate transmission should now become a focus of attention. Not all of them do women have the power to change. A number are treatable. Others, in particular, sexual and infibulation practices, will require longer term solutions. However, there are many conditions that can be improved, through improved hygiene or through treatment.

 Women may be culturally or socially constrained from using STD-dedicated services, or even from seeking treatment for a genital condition. This is often not culturally or socially sanctioned. If we want to enable women to avail themselves of this means of protection, it becomes important to know whether the diagnosis and treatment of these conditions can be combined, for example, with other consultations requiring an internal examination. That is, if women cannot go to be treated for these conditions, can we locate services where they are already being externally examined.

 This analysis will lead to a broader emphasis on, then an exclusive focus on improving STD services. STD services are mainly used by people, men and women, with multiple sexual partners. Most women do not use these services and most women suffer from genital conditions other than, but also including, STDs. Thus, a woman-centred analysis in this area would focus on the diagnosis and treatment of those genital conditions in both men and women which place them at increased risk of infection and would focus on the delivery of services at points where these people go.

 Another strategy for reducing the efficacy of transmission may be to ensure that the change sin a person's infectivity over the course of infection are widely known. A person's infectiousness, the ability to infect someone else, increases as he or she progresses from asymptomatic infection to symptomatic infection. Whereas an individual woman may not be able to refuse sexual intercourse in general, she may be able to find a way if her partner were ill. In other words, she may be able to do this in a short period of time although not over a long period of time. This knowledge about infectivity is an important element in the counselling of discordant couples in our societies. In societies where the virus is diffused throughout the population, this information should be widely known so that those who can, can use it as a protective measure.

 Apart from the above, there are at least two strategies for preventing contact with an infected person, the first type of measure, which are under a woman's control.

 Little attention has been given to barrier methods which, unlike the condom, are under a woman's control. The literature on the sexual transmission of diseases other than HIV to women indicate that diaphragms protect women from, for example, gonorrhoea, to the same extent that condom usage does. There is no reason to assume that condoms protect women more than diaphragms do, with or without a spermicide, in the case of HIV. Yet, no attention has been given to determining the adequacy of diaphragms as a protective measure.

 The second strategy under women's control for preventing contact with an infected man is, in the absence of any known alternatives, becoming more widespread in high incidence areas. This is desertion. that is, just moving away, walking away from home and relationship. It is an option often with tragic consequences for the woman who may well find herself unable too support herself and, when she is able to take them, her children. In such cases, prostitution, and so infection, may be her only coping strategy.

 There is a pressing need to further explore and identify the strategies which a woman may have under her control. However, at the same time it must be understood that the most efficient and effective prevention strategies are those that men have under their control. Thus, every effort must continue to be made to change men's behaviour.

 In this area, also, there has been a great neglect of a woman-centred analysis. There are at least two very powerful instruments that have not yet been fully identified in the efforts to change men's behaviour. the first is women's collective action. The second is the law.

 While women individually may feel and be powerless to change men's behaviour, women collectively can effect extraordinary changes. The literature on the global movement of women over the last couple of decades abounds with examples. The women of Maharastra who decided to no longer tolerate drunkenness in men, in their husbands, formed themselves into vigilante groups. As a group, not individually, the went out looking for the stills and for drunken men. They changed drinking men's drinking patterns. The Chipko women tied themselves to trees to prevent environmental degradation in Nepal. Mexican women in the mid- to late seventies formed an alliance across all types of women and women's groups to bring down the incidence of rape and sexual assault of women. Kenyan women, also tired of drunkenness in their husbands, came together to devise strategies for stopping that behaviour. And the models go on and on.

 There is a need to look for models of women's collective action which have changed men's HIV-related behaviour. The collective voices and actions of women to be called upon can range from the national machineries for women and national women's organizations, all the way to groupings of women at the village level. We learnt in Kenya that if you wish to increase women's income, you cannot give a goat to an individual woman. Traditionally, goats are owned by men. If you give a goat to a woman, the man will slaughter it when he chooses and take the money. What the women did, then, was to come collectively together. If women collectively owned a goat, no individual husband could make such a decision. We need analogues to face this epidemic.

 The second instrument is the law. There is now an extremely effective and very active Women and Law in southern Africa project. At the initiation of this project and for quite different reasons, it was decided that one important area of study would be the newly introduced laws relating to child support. These laws required men to pay for the upkeep of any children that they fathered. What the women and law project has found is that there have been striking changes in male sexual behaviour. Men are now fathering fewer children. Now that they are required to provide for and support those that they father, they father fewer.

 This provides an important model. We have tried for a long time through direct legal intervention in the area of rape and incest to change men's behaviour but with varied success. Here is an example of the use of the law to bring about behaviour change which has been extremely effective.

 While the primary analysis so far has focused on prevention, a similar analysis is needed to determine the potential impact of this epidemic on individual families, communities and economies and, hence, to plan effective and timely responses. Even in, so to speak, the male-centred analysis, we are not very far along the road to understanding, describing and finding effective strategies. But the point I am making is that what we need to do is to start elsewhere, in this area too, to start in women's spaces.

 Let me give you some glimpses of what a woman-centred analysis would reveal.

 Firstly, most women do not know that they are infected. Most women do not want to know. Infected or otherwise, they must still continue with their daily lives. There is no one to take their place.

 For many women who know that they are infected, there is no privacy, no confidentiality. Disclosure is not in their hands. Most women find out that they are infected during pregnancy or when a young child falls ill and is diagnosed. The diagnosis of the child makes public the women's infection status.

 For women who know that they are infected, what dominates virtually every minute of the day are two primary emotions: anger and guilt. Anger towards the person, usually their husband and the person with whom they have so often infected one or more of their children.

 The reality of the lives of these women is that, although, as stated above, probably up to 60 or 80 % of infected women were not infected though their own behaviour, they are blamed as the source of the transmission. The stigma and the discrimination associated with this disease rests too often with women.

 Next, the supportive services required by seropositive women will be more than drugs and medical care. They will range from household care for ill women, child care for their children, emotional support to lessen discrimination, and financial support, as so often they will not have an income coming into the house. The dominant concern for many infected women is the present and future support for and care of their children, particularly since the fathers of those children will often be sick or dead.

 The displacement of women's work from patenting, from productive activities and from community work to care for the sick will have immense consequences within those families and communities. This deplacement, coupled with the high mortality rates in women, could well lead to the disintegration of family structures. This can be seen already in parts of Africa. It will lead to changing patterns of agricultural production and the possibility of decreased food production, and to a decrease in informal sector trading where women trade mainly food. It will lead to shortage of personnel in those formal sectors where women predominate, which still include health and education.

 If one includes in one's analysis of the HIV epidemic an analysis centred on women, whether it be with respect to prevention or with respect to developing strategies for minimizing the impact of this epidemic. it is my contention that different strategies and priorities will be identified which may end up being more effective than the present strategies. This is not an academic or a feminist exercise. For women it is a matter of life and death.

 Putting women at the centre of the analysis leads to quite different approaches and strategies. For women today, the lack of this analysis for the HIV epidemic has already cost perhaps millions of lives, their children. The price is too high to continue with the blindness of the past. We must change.

 Acknowledgements

An earlier draft of this paper was presented at a symposium on Women and AIDS: Strategies for the Future, at the Canadian International Development Agency (CIDA), Quebec, Canada on 6 December 1990.

Biographical Note

Elizabeth Reid is a Senior Adviser, Bureau for Policy and Programme Support, United Nations Development Programme (UNDP), New York. Before joining UNDP, she worked closely with community groups working within the HIV epidemic in Australia and was responsible for the formulation of Australia's first National HIV/AIDS Strategy. She has extensive experience in development theory and practice, including programme design and evaluation in Africa, Asia, the Pacific, the Middle East, and Latin America and the Caribbean.

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