Working to improve equity – in health and gender – in rural Swaziland

‘My memory of men is never lit up and illuminated like my memory of women.’ Marguerite Duras, novelist, playwright, and scriptwriter

2017-03-19 Equity in Swaziland Featured Photo

Images of extraordinary women play on my mind. Full-bodied Make (mother), in a patterned headscarf, sits on an upturned bucket and rhythmically strokes a child with a severe disability. Make’s income as a rural health motivator (~AU $35/month) is less than the monthly cost of maize, so she is compelled to buy food on credit. Since her husband’s death from tuberculosis, she has been the primary caregiver for her three children. A Gogo (grandmother) with shining eyes and a weathered brown face lives nearby. She uses her paltry pension to buy food for her grandchildren. In the garden she cultivates, there are onions, maize and a youthful green tomato plant.

As in most societies, in Swaziland, women largely assume the role of carers, and demonstrate remarkable resourcefulness and ingenuity. Make and Gogo are no exception, creating, caring and giving life in the midst of scarcity.

Swaziland is a country in southern Africa with a per capita GDP of less than US $10,000 per year, the world’s fourth lowest life expectancy, and the highest prevalence of HIV/AIDS in the world.

The HIV prevalence is 31% in women aged 15-49 years, compared with 20% in their male counterparts. AIDS has wiped out an entire generation of young adults. Other times, poverty and patriarchal, patrilocal, exogamous relationships are implicated in the neglect of Gogos by family members.

Too often, explanations for the high prevalence of HIV/AIDS are reductionist and prevention strategies narrowly focused. Prevention models which focus on individual behaviour change have been largely ineffective in Swaziland, especially amongst those who lack agency.

Whilst increasing awareness of HIV/AIDS has some success with the affluent, structural factors and policies prevent the disempowered and poor from altering risk behaviours and translating knowledge into behaviour change.

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Lomasoltfo* is a young, pregnant mother of five. Her husband performs back-breaking labour three months of the year on a sugar cane plantation, and is unemployed for the remaining nine months. As a casual worker, he has no job security and no access to benefits.

Neoliberal economic policies – structural adjustment programmes and free trade agreements – have resulted in declining economic growth, deepening poverty, insecure access to affordable anti-retroviral therapy (ART), increasing unemployment, and the decline of subsistence agriculture.

These latter two drive labour migration, which is associated with high-risk sexual behaviours amongst migrating plantation and mine workers, and an increased risk of HIV transmission for both men and female partners. Gender inequality allows men to refuse condom use during sex.

Lomasoltfo’s children experience abdominal cramps from drinking water from a dam shared by animals. 39% of pregnant women in Swaziland are HIV positive. Whilst women are increasingly started on ART during pregnancy to prevent vertical transmission, food insecurity and lack of access to clean drinking water do not bode well for the health of Lomasoltfo’s future baby.

There are added dimensions of vulnerability for girls and women.

I vividly remember a 22 year old orphan heading a household of girls. Robbers had stolen their goats, encouraged by the lack of males on the homestead. Kiyena* wants to be a teacher but will struggle to pay school fees this year. Not completing high school will limit her employment opportunities; a reality all the more troubling given income and food insecurity drive many women to engage in transactional and commercial sex for survival.

The myopic approach seen in mainstream prevention campaigns is akin to some ‘physicians whose professional gaze rarely extends beyond the individual’.

Knowledge is inadequate, without empowerment of the individual to effect change. This is the premise of Possible Dreams International (PDI), a non-profit which empowers families and communities by targeting the social determinants of health.

PDI embodies sustainable, grass roots community development. Make Shongwe (pictured above) is PDI’s determined community champion for Matsetsa, a rural community in Swaziland.

Make lives in, and knows Matsetsa intimately. She identifies new clients with acute needs, follows up Income Generation Projects, provides moral support, and will be running Matsetsa’s new soup kitchen for elderly Gogos.

She also coordinates the Matsetsa Women Project: a group of women making and selling soap and floor polish. The cohesiveness of the group is largely due to their similar interests, shared ownership and supervision by a community champion without a personal stake in the co-operative. Incredibly, the group have already set aside some profit for assisting orphans.

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Thembi (pictured above) is PDI’s confident, resourceful Director of the Empowerment Program. She tells wickedly funny stories and is a powerful singer. PDI’s Swazi team and community champions have a nuanced understanding of what will and will not be successful, and their shared language, culture, community membership and experience encourage people to approach PDI for assistance.

Another Gogo, with a beaming grin and big plans for expanding her street shop, wants to sell fish and Russian sausages (local favourites) to other community members. PDI helps to cover her medication costs, and will support her local business by connecting her to someone with a fridge, and helping her access supplies. In this way, PDI upholds the dignity and agency of individuals.

These are a few of the women of Swaziland, seen in their diversity and complexity. Together, they illustrate the challenges to health for women in Swaziland, and the ways in which women are healing the deep wounds of inequity.

*All names have been changed. Stories and photos used with permission.

Dr Nishani Nithianandan is a Board Member of Possible Dreams International. If you would like to know more about Possible Dreams International or become involved in their work, head to their website.

The views and opinions expressed in this article are those of the author and do not necessarily represent those of the Doctus Project.