Within the context of social, political, and economic inequality, South Africa is extreme

It is also the only country in the world where racial discrimination is enshrined in the constitution and this has impacted enormously on the health of Africans, and in particular African women. 1 Gender inequality, poverty, violence and low social status have continued to undermine women’s health in South Africa’s strongly patriarchal society. These social realities have led to a proliferation of health related problems, the most serious of which is the HIV/AIDS pandemic.

Given women’s critical roles as mothers, food producers and income earners, the social, economic, and political systems within South Africa’s highly stratified society have figured predominately on their well-being and that of their children. Therefore, any health related discourse in South Africa must take place within a political and socioeconomic context. The objective of this paper is to first provide a brief historical analogy of gender inequality, and how it has continued to negatively impact on the health of African women.

I will also discuss how the inferior socioeconomic and cultural status of black women has led many of them to live lives characterized by persistent poverty and inadequate and or unequal access to healthcare facilities. Furthermore due to their vulnerability within society, these women have borne the brunt of the of the HIV/AIDS pandemic and I will discuss the synergistic impacts of this disease on South African society as a whole. Long conditioned by previous generations, male domination within indigenous South African society has continued in order to maintain a woman’s subordination, dependency, and low socioeconomic status.

Inlonipho, the patriarchal code of “respect” has continued to be enforced by physical violence, rape, assault, emotional, psychological, and economic abuse (Mager, 1999). The historical roots of these social systems are highly complex, but lie mainly within the nature of South Africa’s overtly patriarchal society, and most importantly, the progressive moral, social, and economic disintegration of the family unit due to ongoing white dominated political regimes. At the turn of the century, South Africa’s white dominated mining industries legally enforced migratory black labour systems.

This regimented system was also the product of political pressures and the economic need for cheap labour within South African society (Callinicos, 1985) Uprooted from their ancestral farmlands, thousands of men were forced to work in appalling conditions amid squalor and disease. Denied the right to live with their families, this led to a “loosing” of family and community ties, as men were exposed to the negative influences of urban living conditions, which included alcohol and extramarital sex, thereby losing touch with their community mores. Baker, 1989 and Hunter, 2002: 106-107) Thus, the new urban economy fundamentally shook the system of sexual practices as non-marital sexual relationships became more common and this has been demonstrated by the notably high rates of STDs at the beginning of the 20th century. Migrant labour also resulted in a gender ratio imbalance, with an excess of males in the urban areas and female-headed households in the poor rural areas.

Rural employers paid minimal wages, which were insufficient to feed and clothe and entire family making it impossible to meet the social cost of reproduction. 2 This early form of “robber capitalism” by white industry ultimately forced women into low paying domestic work. These crippling economic circumstances along with more single parent families further contributed to the breakdown of the domestic unit while trapping women and children amid conditions of poverty, disease, and widespread infant mortality (Mason, 1997: 231-251).

With the introduction of apartheid in the late 1940’s, further racist legislation led to increased poverty, deteriorating social conditions, including gendered power relations and violence by confining the majority of black South Africans, by way of massive forced removals, to live in the poorest “ethnic enclaves” or Bantustans (Mager, 1999). When these rural areas were created for “separate development”, this exacerbated the already poor health conditions of the African population, and in particular, women and children.

The government frequently failed to provide access to safe or adequate water supplies, housing, sanitation services and public healthcare facilities (Horrell, 1963). Aside from the political and economic impacts on health, migrant labour had a “domino effect” by contributing directly to a multitude of chaotic social structures including adultery; marriage breakdowns, illegitimate births and escalating gender related violence.

It is axiomatic that the disruption of family structures by the colonial and apartheid systems had tremendous health impacts on the majority of African women and children, and in South Africa today this is no more evident than with the proliferation of the HIV/AIDS pandemic. Understandably, after decades of socioeconomic marginalization, discrimination, alienation, inequality, and violence, women, especially of childbearing age have been hardest hit by this epidemic.

Furthermore, lack of education, low social status, and economic dependence have continued to affect a woman’s ability to make decisions regarding a majority of health issues, especially contraceptive use. As a result of its social history, gender inequality has flourished, and continues to be part of the South African male identity (Abrahams ; Laubsher 1999:3). Until recently, historical records on the social epidemiology of women’s health have been limited, and for the most part “gender-blind”. However, in 1999, a large-scale community based study, conducted by the Centre of Epidemiological Research in Southern Africa (CERSA) shed further light on the social and demographic characteristics of gender related health problems especially within the context of violence. (Jewkes et al, 1999)

Their main findings were that: * Emotional, psychological, financial and physical and sexual abuses are common features of most relationships. * Physical violence often continues during pregnancy and constitutes and important cause of reproductive morbidity. Many women are injured by their partners, and considerable health sector resources are expended by providing treatment for these injuries. * Injuries and diseases result in costs being incurred by other sectors, notably within the family, the community, employers and the national economy. Psychological abuse also contributes to high levels of stress related illnesses such as emotional problems, which by far are the most debilitating (Adar & Stevens 2000:422).

Often, the stress from physical abuse leads to so much psychological damage particularly when a woman is socially and physically isolated in poor rural communities and her ability to effectively care for herself and her children is often severely compromised. Unfortunately, many men are not conditioned to have healthy relationships and their solution to resolving their inner-conflicts is through anger and rage.

By holding their partners responsible for their behaviour, men often accept no liability for their actions, regardless of the enormous psychological and physical trauma they inflict, even if their actions result in death (Jewkes 1999). A 1999 study conducted by the Medical Research Council of South Africa revealed that almost 50% of men who were abused as children were at a higher risk of violent behaviour towards their partners (Abraham, Jewkes & Laubsher, 1999:5-7).

Similarly, their research findings also found that health problems, specifically emotional and psychological, resulting from domestic violence were significantly more common among women who had experienced physical abuse during childhood while challenging traditional gender norms with more “liberal” ideas. 4 Given the crucial importance of women within African society as mothers, nurturers, food producers, and income earners, their roles are understandably threatened by ill health.

Also, with diminished socioeconomic status within the household, especially in rural communities, women are often forcibly isolated from their family and friends, which further restricts their ability to effectively retaliate, seek medical attention, or leave their abusive partners for fear of repeat victimization. Compared to their white counterparts, African women, especially in the poor rural areas, often have little or no access to healthcare facilities, and when their mental, psychological, or physical health is at risk this can pose an enormous problem. It is important to understand that in South Africa’s highly stratified society there is an enormous bias towards high tech curative medicine. Within the more prosperous private sector, white patients receive five times as much funding as those in the public sector and less than 6 percent of state funding is targeted towards preventative medicine (Nagle, 1995:112) South Africa is also noted for its high technology, 6privately run Western-style medical healthcare system and services.

Thus, the pattern of disease and mortality that has evolved shows that the more affluent whites experience relatively more degenerative diseases such as cancer, hypertension, cardio and cerebro-vascular diseases. Conversely, blacks and coloureds are more prone to infectious and contagious diseases along with stress related illnesses that are mainly the result of the lack of decent housing, adequate sewage disposal, clean running water, and generally unsanitary living conditions.

Poverty however, remains the primary cause of the prevalence of many diseases such as tuberculosis, cholera, and STDs. For women gender inequality and low social status conspires with poverty, which leads to a higher incidence of health related problems, and within the past decade HIV/AIDS. Children in particular are affected by diseases of malnutrition namely kwashiorkor and to a lesser extent, marasmus (Seedat, 1984:24).

In South Africa, national wealth and income disparities are skewed in favour of the minority elite with the greatest majority of blacks living in poverty. On a macro level, these factors along with social development, lack of employment, population growth, and government allocations to healthcare have a direct bearing on health. Studies have shown that the shape of the HIV epidemic is determined by two key variables, one being the level of social cohesion and the overall levels of wealth and income distribution.