Prevention and management of reproductive tract infections in a slum in Kingston, Jamaica
Cairo, Jamaica, and Real Life in the Streets of the Ghetto
Von Denise Chevannes-Vogel / Schweizerisches Tropen- und Public-Health Institut (Swiss TPH)
An important shift has occurred in population thinking in the last 25 years. In 1974 the first World Population Conference in Bucharest advanced the argument that "development is the best contraceptive’ and underscored the rights of couples to family planning, education and services. However, by 1994 this had evolved into a much broader mandate so that the consensus of the International Conference on Population and Development (ICPD) convened in Cairo in that year called for innovative, development-related policies grounded on notions of human rights, equality and equity. Notably, population issues of fertility, mortality and family planning were now located in the broader, integrated context of reproductive and sexual health, human rights and sustainable development. But 5 years later, what practical significance does ICPD hold for poor families in developing countries? Have those ideals which were proclaimed in the spotlight of global fora trickled down to the streets of urban slums far away from the limelight? Citing from empirical research conducted in Jamaica, this article will focus a micro-level perspective on the reproductive health behaviours of men and women in the social and economic periphery, those persons whose well-being and full participation, the ICPD asserts, is so critical to sustainable development. The article concludes that reproductive health is not only a human rights issue but also one whose absence signals existing social, economic and political inequalities within countries as well as between the First and Third World.
An important shift in the conceptual thinking concerning population and development issues has occurred in the last 25 years. In 1974 the first World Population Conference in Bucharest advanced the argument that "development is the best contraceptive" and stressed the rights of couples to family planning, education and services. However, by 1994 this had evolved into a much broader mandate so that the consensus of the International Conference on Population and Development (ICPD) convened by the United Nations in Cairo called for innovative, development-related policies grounded on notions of human rights, equality and equity. Specifically, instead of focusing on demographic targets for population control, family planning was now located in the context of reproductive and sexual health care, and women’s empowerment, and seen as part of a larger human rights issue. But what was the thinking that led up to ICPD? It did not, after all, occur in isolation of other debates on social and development issues which had been taking place in the era. In the intervening years between the Bucharest conference and the ICPD, several other international efforts and meetings have taken place which have focused attention on the centrality of the well-being women and men, as well as human rights, in sustainable development. The way in which these have shaped the reproductive health debate shall now be examined.
1. The paradigm shift
In acknowledgment of the vital imperative to improve the situation of women in development elucidated at the Bucharest Conference and during International Women's Year in 1975, the United Nations General Assembly declared 1976-85 the United Nations Decade for Women. The Decade focussed attention on women and mobilized an effort to address critical development issues of the era, including health. The launching took place against a background which included a number of social protest movements in the sixties and seventies such as Third World protestations about the injustice of the international economic order, liberation struggles and civil rights movements; the recognition of the failure of the first development decade and innovative directions for the second; and, acknowledgment of the linkage between the development process and the situation of women and the fact that the latter had been adversely affected in the relationship.
The meetings included the World Conference to Review and Appraise the Achievements of the United Nations Decade for Women: Equality, Development and Peace held in Nairobi in 1985 and the World Conference on Human Rights convened in Vienna in 1993 (UNFPA 1996). The Nairobi Conference highlighted the awareness that women’s reproductive and productive roles are closely connected to their social, cultural, economic, educational, political, legal and religious circumstances. It also noted that "an improvement in the situation of women can bring about a reduction in mortality and morbidity, better regulation of fertility and, hence, population control, which would be beneficial to the environment and to the women, children and men whose lives depend on it for sustenance". The Vienna Conference which followed 8 years later was the first United Nations conference to address all aspects of human rights and to confirm the right to development as an integral part of human rights and fundamental freedoms. The consensus at that meeting was that the protection and promotion of these rights would be the corner-stone on which social and economic development, stability, security and peace could be built. In particular, it was noted that the human rights of women and the girl child were an "inalienable, integral and indivisible part of universal human rights" and that access to adequate family planning services and education were a part of women’s rights (UNFPA 1996).
By 1994 when the ICPD was held in Cairo there had been a cross-fertilization of issues from the United Nations conferences held in the previous decades so that the integral relationship between population and development was reiterated but a human rights lens had now been added. Beyond establishing demographic goals, addressing the needs of men and women and emphasizing their human rights, especially their reproductive and sexual rights, had become a part of the equation. A major factor in the approach was the empowerment of women who, it was envisioned, would be able to fully enter the labour market and participate in decision-making and policy formulation once their potential had been actualized. Another significant element in the approach was the call for the active involvement of all groups in civil society in population and development programmes, particularly those relating to reproductive and sexual health. There was now the notion of investment in human development and an expanded, integrated framework of reproductive health, human rights and sustainable development in which population issues of fertility, mortality and family planning were now located (see Figure 1). The ICPD Programme of Action reflects this shift and notable elements which directly influence reproductive health included a focus on:
- gender equity, equality and empowerment;
- facilitation of women’s human rights, particularly their reproductive and sexual rights;
- prevention and treatment of sexually transmitted diseases (STD) including HIV/AIDS
- promoting male involvement and responsibility;
- elimination of all forms of violence against women;
- elimination of poverty, in particular the feminization of poverty; and
- addressing adolescent sexual and reproductive health and services.
With specific reference to reproductive health, some of the strategies of the ICPD Programme of Action included:
- prevention of unintended pregnancy through family planning services;
- provision of safe pregnancy services to reduce maternal morbidity and mortality;
- provision of post-abortion care and safe abortion services where these are permitted by law;
- Ensuring male responsibility for family planning, and sexual and reproductive health; and
- prevention and treatment of reproductive tract infections (RTI) and sexually transmitted diseases including HIV/AIDS.
2. Jamaica: An Illustration of ICPD in Action
Attention will now be directed to a concrete example of how the ICPD Programme of Action has directed population and development policy and been implemented in practice in a developing country. Policy makers from Jamaica were among the representatives from 177 Member States who were present in Cairo and the way in which the consensus arrived at in Cairo has influenced reproductive health policy in this setting will be briefly reviewed. Jamaica’s Evolution from Family Planning to Reproductive Health
Family planning services were first introduced in Jamaica in the 1930's by non-governmental organizations (NGO). The Government of Jamaica formally adopted a family planning programme in the late 1960's and in 1970 formed the National Family Planning Board (NFPB) as a statutory body of the Ministry of Health . The population policies that evolved through the 1980's and until 1995 were based on prevailing demographic, social and economic conditions and focused on population size, fertility, mortality, external and internal migration (PIOJ 1995a). After the Cairo meeting in 1994, the national population policy was revised in 1995 to reflect the objectives and recommendations of the ICPD Programme of Action and the plan included a chapter on reproductive rights and reproductive health of which the terms of reference entailed:
- Addressing the needs of individuals and couples for a range of safe, effective, and affordable methods of fertility regulation;
- Reduction in maternal mortality and morbidity as well as perinatal mortality and morbidity;
- Prevention and management of reproductive tract infections, including STD’s and HIV/AIDS; and
- Provision of services for the early detection and management of cancers and other conditions of the reproductive tract.
The most well-developed elements of reproductive health in Jamaica to date have been programmes to address family planning, maternal and child health (MCH), and STD/HIV/AIDS.
This article will focus on one area of reproductive health: the prevention and management of reproductive tract infections, including STD’s and HIV/AIDS. Firstly, a micro-level perspective will be focused on the stark reality of the lives of men and women in an urban slum in the capital city, people at the very edges of the social and economic margin. These are the persons whose well-being and full participation, the ICPD asserts, are so crucial to sustainable development. Secondly, their health behaviours in relation to sexually transmitted diseases will be examined to see what relevance the reproductive health debate has in the actuality of their lives.
3. The Urban Reality: Jam Town
Research was conducted by this investigator in Jam Town, an inner-city community located in the west of the capital, Kingston (Chevannes-Vogel 1999). Jam Town was constructed 50 years ago by the then colonial authorities as part of a large-scale development which would meet the housing needs of the urban impoverished in close proximity to the city centre, where labour opportunities, food and sources of income were more readily accessible. In the ensuing years, however, the area has witnessed massive deterioration and destruction of one kind or another. Many areas have been burnt out in a kind of political "cleansing" and everywhere there are signs of decay and neglect - cracks in the slab and concrete walls; splintered roofs and windows; broken pipes and toilets. Violence continues to claim the lives of many in the community and has affected every aspect of people’s lives including their access to social, economic, education and health opportunities.
The constraints to disease prevention and health promotion in Jam Town are numerous. The most obvious is the almost universal lack of toilet and sanitation facilities in the area. The situation regarding access to water is less severe but a substantial proportion, 37.3%, have no direct access to water. There are pools of stagnant water from choked and broken sewerage mains and during periods of heavy rainfall, raw sewerage water rises and courses through the streets. The health hazards posed by the lack of water, sanitation and sewerage facilities and vector control activities are only aggravated by the limited access of this population to health services.
The only clinic service offered in the area is provided through a non-governmental health post which offers limited maternal and child health services such as basic antenatal care and immunization services. The next closest primary health care facility is a clinic offering slightly more services but it is located in a politically hostile territory and very few people take the risk of going there. North of Jam Town is a large health facility offering a wide range of services including prevention and control of sexually transmitted diseases, but it is difficult to access and has the stigma attached to it of being a service for people with STDs.
4. Jam Town Rock: Life in the Ghetto
Everyday life in this inner-city community is a constant struggle. In addition to the environmental decay and lack of access to health services which residents face, they have to contend with a number of social and economic obstacles which may have a direct bearing not only on their reproductive health behaviours but also on the occurrence and outcome of sexually transmitted diseases.
Unemployment is high at 39% and although 27% claim to be self-employed they very often earn less than subsistence income from their activities. The effective figure for under- and un-employment is therefore in the region of 66%. Unemployment is significantly higher among women than among men. Those persons who are employed (23%) are in low wage, low status occupations such as domestic helpers, casual labourers, or factory workers who sometimes earn less than the minimum wage:
Me used to go out and wash for people but dem no give me no right money. Me never really go and do factory work. Factory work is for people who have no kids. Yuh have to get up early and look bout de kids. Me would lose de work. Plus yuh have to find busfare and lunch money. (27 y.o. woman)
In them time is better you living more than you dead cause it is very hard to bury a dead now, you know. $65, 000 de lady pay to bury her son that dead up a Fifth Street, so me always pray to God dat's nuttin don’t happen to me. (35 y.o. woman)
4.2. Multiple regular sexual relationships
Sex (i.e being male or female), low education levels, and early age at first sexual intercourse were some of the explanatory variables found to be significantly associated with maintaining multiple regular sexual relationships. A regular sexual relationship is defined by WHO as one lasting more than 12 months. The working definition of multiple regular sexual relationship being used in this study is having a regular sexual partner of 12 months or more in addition to the person identified by the respondent as the consensual partner.
Among persons with multiple regular sexual relationships there were more men than women (54% of men vs. 30% women); more people with less than 8 years of education (71% vs. 29%); more persons who had their first sexual intercourse before 16 years, the age of sexual consent (51% vs. 16%). Gender status was also found to influence whether of not a person had multiple regular sexual partnerships. 40% of female household heads had multiple partners, none of the female partners had. These differences were statistically significant. Both male gender groups had high proportions of multiple partners with male household heads showing an excess (61% v. 42%), the difference not being statistically significant.
Men and women gave different reasons for the maintenance of multiple sexual partnerships. For women it was primarily for economic support of their families and in view of the higher unemployment among women, this finding is not surprising:
Yeah, is 10 years now since me been wid dis outside guy. Him help me wid de kids and dat's why me hang on. Me nuh too like it cause him wild. Him is a young man, younger than me, and every girl him want to go to bed wid.... But me nuh have no other choice cause if it wasn't for him we wouldn't even eat dinner this evening. De school fees, is him give me money to pay. Me cyan mek me husband know, me tell him say is borrow me borrow de money. All me do is pray me nuh get AIDS... Me sleep wid him at nights for all one week or 4 nights. De money part is a Thursday so me have to mek sure dat me is there on a Thursday. Me husband, me think him know, but him don't ask me no question cause him not minding us. (39 y.o. woman)
For men on the other hand keeping multiple partners is very often for sexual adventure and variety, proving their virility, and gaining status in the eyes of other community members, particularly their male peers. Some younger women enjoy being known as the girlfriend of a man who has status and recognition in the eyes either, because he can afford expensive clothing or, is a "soldier" charged with community protection, since they themselves gain societal validation in this way. Respect is an important notion for the dis-empowered, those who perceive themselves to be "the other" that the rest of society has rejected:
At times some other girls come around but most of them just come and go, come and go. You have girls that see you and like you and decide to take a piece. There are girls who see me and like me, like how me carry meself. If them look attractive to me, me will decide to take a piece too. (25 y.o. man)
You see here in the ghetto you have girl that just love name-brand guy and face boy. From the clothes and shoes that you wear them just want you. You see if you wearing a Fila crepe (shoes), name brand jeans and shirt you have them weak, you don't even have to give them a cent. Is them things them love. You don't even have to have a house, you just carry them 'round the back of the yard and do it there. You know it come from the dancehall, from the music. When the DJ selector say, "Put up you hand if you man wear name-brand!!", is that them want do. (22 y.o. man)
4.3. Early sexual initiation
Children grow old fast in the ghetto. Living in overcrowded rooms, bathing out in the open in the yard where there is no privacy, surrounded by the loud pulsating sounds of dancehall music some of whose words declare, "yuh have to get a slam (sex) from a real ghetto gal!", they become initiated into sexual activity early in their lives. Among the entire study sample, 69% of men had had their first sexual experience before the age of 16. For women this figure was 48% and the difference was statistically significant.
Young adolescent girls face a particular risk. It seems that the inadvertent result of a traditional, epidemiological approach to the prevention and control of STD/HIV/AIDS which entails defining high risk groups, such as commercial sex workers, has served to redirect risks to this newly vulnerable group, the girl child. Men often perceive young girls, who are more malleable and more easily controlled than older women, to be uninfected and there is a myth that having sex with a virgin will cure a man of gonorrhoea:
Me cyan let her go. Cause you see in de ghetto, some man see you little daughter and see how you a raise them good, and them start fishy-fishy at you gate, start call them and put argument to them. (35 y.o. woman)
4.4. Sex as an exchange commodity
There is a pervasive notion that sex has an economic value which can be exchanged. Transactional sex occurs and 35 % and 38%, respectively, of all women and men had engaged in this practice at some time in their lives. This is not, however, considered to be prostitution which has connotations of intemperate promiscuity and moral looseness for both men and women:
You have to give money, you can't look on a woman and use a woman. You have to give her something and make her feel nice just like how she make you feel nice. (34 y.o. man)
Yeah as me tell yuh dat have to go on for de children dem to survive. Dat's how dem go school, dat's how we eat, dat's how we have dinner this Sunday evening. (39 y.o woman)
Yuh have to know how to flex to survive and when me first babyfather did dead me had to find a way. Me never was a prostitute. It was wid a man me did know and me ask him for food money and him say me must lie down for it. (28 y.o. woman)
Again, adolescent girls are at particular risk. The economic situation and the view that sex is an exchange commodity encourage some girls to actively seek out the attention of men and some mothers tacitly or overtly support this practice:
And some of de little girl them, all 12 year old, but them look like them 15, them love it. Them man say them don’t want no old woman, them want young blood. Some of de mothers them will all send them daughter out go look man cause them lazy and don’t want look work, them want sit down. Them will see them daughter come in de house with tings, and them don’t ask where them get it from till it too late. Dat time it done bad already, de gal pregnant already, she start breed. (35 y.o. woman)
4.5. Gender socialisation
In trying to protect their girl children from the risks of teenage pregnancy, in trying to prevent these pubescent women from falling again in the same cyclical trap of adolescent fertility, repeated pregnancies, and blunted economic opportunities that they themselves fell in, many mothers socialise girls in the private domain. Such social isolation from the rest of the community and the wider society suggests that girls may grow up to be less assertive and street-wise than boys, at least until circumstances force them to be. Among all women 44% often or always thought that other people could stand up for themselves more than they could. The comparable figure among men was 25%.
Me tell God to guide me in and out. If anyting happen to me right now, me children going suffer, so me pray dat me going live out me days. Me fret (worry) over me daughter cause she is 12 , and is ghetto she live and friend lead them astray. Dat's why me don’t make her keep no friend. Me make sure tell her when school over she must come home, me don’t want her on de street a play. Is in de yard she must grow. (35 y.o. woman)
Domestic seclusion has implications not only for girls lack of assertiveness but also for the type of training and educational choices they select in school. They may choose traditional, feminized and, eventually, poorly paid options such as garment making and hairdressing which will limit their future income earning potential. A key informant interview with the director of a community vocational school corroborates this argument.
Boys, on the other hand, are socialised in the public domain where parental control is less strict and is not predicated on control of their sexuality. Quite the contrary, early sexuality as a rite of passage into manhood is tacitly encouraged because it proves that he is not homosexual, an enormous taboo especially among the working class in Jamaica. Parental control over boys lies in trying to keep them out of gangs, drugs and violence and out of the way of the police.
4.6. Women’s lack of power over their reproductive health
Fertility is socially valued for both men and women in this community. For a man it is a sign of virility and potency and the more babymothers he has, the more potential sex partners he is assured of since "a babyfather has all rights and privileges over his babymother", rights without responsibilities. For a woman, it proves she is not barren, not a "mule". Having a child for a man is also a way to bring stability to a union and ensure economic support.
Me tell him now say if me get pregnant for him me don’t want sorry. Him say how me don’t know what kind of nice plan him have for me. But some man just tell yuh so and when yuh tek a stock nuttin like dat. Every one of dem man is de same ting dem face woman wid.. Me used to tek family planning but me stop last month cause me want have a baby for him. (30 y.o. woman)
Me say alright since me find a little man cause me nah tell no lie, yuh understand, me like him. Him check for me and him check for me children, so since me find a little man me going ease off de family planning and me and him try to get along wid we life and so forth. Me want have a child for him. (35 y.o. woman)
The contraceptive Pill and injection are the family planning methods most commonly used. Family planning is generally viewed as unnatural, a foreign substance that changes a woman’s body odour and vaginal discharge as well as disturbs the flow of her menstrual blood. The concept of flow is important in the Jamaican ethnomedical view and anything that causes obstruction or blockages is perceived as being deleterious to the body. Hormonal contraceptives are viewed by many women as an undesirable but necessary evil to prevent further pregnancies.
Me don't tek de injection straight. Me will ease off and rest me body for all 1 year till me see me period normal. Dem say yuh don't healthy when yuh don't see yuh period. It not good when yuh don't see yuh period. (24 y.o. woman)
Women are sexually subordinate to men. Over half (58%) of women had had sex against their will with a partner because they could not find a way to stop it.
Nuff time me babyfather force and tek it. More time him would even tear off me clothes. Rape me would a call dat. Is rape cause from yuh decide not to give sex and him tek it, is rape. Tru dat it mek me feel vex towards him. Him have it to say dat tru we is babymother and babyfather him have de right to do dat. (28 y.o. woman)
4.7. Sense of hopelessness
Finally, the disabling poverty, sense of powerlessness, and violence imbue many people with a sense of hopelessness and suggest that they will have lowered levels of self-esteem, self-confidence and locus of control to undertake positive behaviours for their reproductive health. Over 60% had lost a close family friend to violence in the 6-month period prior to the interview and nobody feels safe and men, women and children all face threat of attack. Not surprisingly almost 60% admitted to having had the feeling that they were not in control of their lives.
Nuff times in here at night me fret cause tru de war wid Garden man dem could kick off de door and shoot anybody dem catch. Yuh could be big or small, dat don't matter, dem going shoot yuh. (28 y.o man)
All de time dat's a problem. Me is alone and me have de children and it rough. Sometimes me see dem want certain things in life and me can't afford it. Even if it not dear but me still can't find de money. Sometimes me feel frustrated and ignorant of dem cause dem looking at me and me see dem want dis and dat but me don't have it to meet dem needs. (34 y.o. woman)
It must be stated that substantial gains have been made in reproductive health in Jamaica. The total fertility rate fell from 5.3 in 1970 to 2.8 in 1997 (McFarlane et al.1998). Contraceptive prevalence increased from 56% in 1989 to 63% in 1993, much of the increase being attributed to condom use (McFarlane et al.1994).
Nevertheless, some of the constraints to reproductive health that the urban poor, especially women and adolescents, face have been illustrated here. These findings indicate the necessity for targeted interventions. The high fertility rate documented among Jamaican adolescents by McNeil et al. (1983) and Barnett et al. (1996) of 108 births per 1,000 women aged 15 to 19 years attests to this too. These rates are among the highest in the Caribbean. STD prevalence rates are also high and a recent study in a sexually transmitted disease clinic in Kingston noted that 54% of the women had at least one STD (Behets et al. 1995). There is also evidence that HIV infection is spreading and Jamaica may be on the brink of a significant increase in AIDS over the next decade. By the end of 1996, 2060 cases of AIDS had been reported since the first case in 1982 and the increase has been most rapid in women. Prior to 1987 in Jamaica, there were no diagnoses of AIDS in women but by 1996 women had accounted for approximately 38% of cases. It is clear, then, that much remains to be done but how shall this be accomplished?
Singer and Baer (1995) have proposed a critical medical anthropology approach which advocates a multi-level examination of the shaping of ill-health and this is a useful context in which to locate the problem of reproductive health in Jamaica and possibly, its resolution. There are four inter-connected, analytical levels in this framework, namely, what the writers call macro-social, intermediate-social, micro-social and individual and it may be worthwhile to consider possible interventions at these levels.
At the individual level, the present study has demonstrated the kinds of problematic reproductive health behaviours which may occur and suggests the need for interventions that address issues such as individual self-esteem, empowerment and capacity for agency. At the micro-social level may be included interventions to address household health behaviours and decision-making while needed at the intermediate-social level are interventions to improve the social relations of gender and gender socialisation practices.
At the macro-social level are the socio-demographic and economic conditions existing in Jamaica which pose serious restrictions to being able to fully implement the ICPD recommendations and agreements. Among the most important that need to be addressed are:
- fragile national economic climate compounded by unfavourable international financial, economic and trade arrangements;
- persistent poverty, especially among particularly vulnerable groups such as female heads of household;
- inadequate employment generation, particularly in high-productivity sectors;
- shortcomings in social and gender equity;
- limited funding and human resources in the public sector;
- diminishing donor funds as donor fatigue gains ascendancy and political interests shift away.
In the context of developing countries, this writer suggests that another level of analysis and intervention needs to be added and that is, the global inequalities between the First and Third Worlds. Structural adjustment programmes still continue to create a harsh social and economic climate in developing countries. The end of the cold war and a different political and development agenda have seen donor funds shifting from Latin America and sub-Saharan Africa to Eastern Europe. International policies on trade liberalisation and globalisation may soon have an unfavourable impact in some developing countries which can not be competitive as they are unable to take advantage of larger economies of scale. The current banana trade impasse between the United States and Europe in which former European colonies in Africa, the Caribbean and the Pacific (ACP) risk losing preferential access into the European market is a case in point. Interventions to provide debt relief and more equitable terms of trade would make available for use in the health and social service sector, funds that currently go into debt repayments.
In conclusion, reproductive health is not only a human rights issue as the ICPD noted but, in the context of the poor in developing countries, is also an economic and political issue. In addition to addressing the social, gender, economic and political inequalities within countries which create an under-class who are unable to realise their health potential, it is also necessary to examine the global inequalities between the North and South. Until these issues are dealt with it is unlikely that the problem of reproductive health, and indeed health in general, in developing countries will be resolved any time soon. This needs to be the next paradigm shift.
*This article is based on Denise Chevannes-Vogel’s dissertation "Gender and health behaviours in relation to sexually transmitted diseases: The case of an urban ghetto in Jamaica" at the University of Basel (1999).
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