In Namibia, a generations-long tradition of tapping the sap of palm trees runs counter to recent environmental protection efforts. Is this an essential cultural practice or merely destructive? These striking portraits investigate. The images in this series portray the Himba men who select, prepare and maintain Makalani palms during the sap tapping process. The Himba people from this area have utilised this plant family for generations, passing down the knowledge and technique needed to carry out the process of obtaining the liquid. Although the Makalani palm is a protected tree in Namibia and the tapping of palms a banned practice, the Himba firmly believe that it is their right to continue the tradition. They argue against Western law and instead follow ancient cultural traditions that respect these palms through their utilisation. In turn, they promote their conservation on a local, cultural level.
Poverty and health
Tobacco use among people living with HIV results in excess morbidity and mortality. However, very little is known about the extent of tobacco use among people living with HIV in low-income and middle-income countries (LMICs). The authors assessed the prevalence of tobacco use among people living with HIV in LMICs. The authors used Demographic and Health Survey data collected between 2003 and 2014 from 28 LMICs where both tobacco use and HIV test data were made publicly available. They estimated the country-specific, regional, and overall prevalence of current tobacco use (smoked, smokeless, and any tobacco use) among 6729 HIV-positive men from 27 LMICs (aged 15–59 years) and 11 495 HIV-positive women from 28 LMICs (aged 15–49 years), and compared them with those in 193 763 HIV-negative men and 222 808 HIV-negative women, respectively. The authors estimated prevalence separately for males and females as a proportion, and the analysis accounted for sampling weights, clustering, and stratification in the sampling design. They computed pooled regional and overall prevalence estimates through meta-analysis with the application of a random-effects model. They computed country, regional, and overall relative prevalence ratios for tobacco smoking, smokeless tobacco use, and any tobacco use separately for males and females to study differences in prevalence rates between HIV-positive and HIV-negative individuals. The overall prevalence among HIV-positive men was 24·4% for tobacco smoking, 3·4% for smokeless tobacco use, and 27·1% for any tobacco use. The authors found a higher prevalence in HIV-positive men of any tobacco use (risk ratio [RR] 1·41 and tobacco smoking than in HIV-negative men (both p<0·0001). The difference in smokeless tobacco use prevalence between HIV-positive and HIV-negative men was not significant. The overall prevalence among HIV-positive women was 1·3% for tobacco smoking, 2·1% for smokeless tobacco use, and 3·6% for any tobacco use. The authors found a higher prevalence in HIV-positive women of any tobacco use, tobacco smoking and smokeless tobacco use than in HIV-negative women. The high prevalence of tobacco use in people living with HIV in LMICs mandates targeted policy, practice, and research action to promote tobacco cessation and to improve the health outcomes in this population.
Born 1994, Tshepo Jamillah Moyo (TJ) is an unapologetic black Pan African Inter-sectional Feminist performance artist. Her work centres on the exploration of black African womanhood. In this conversation, she discusses her provocation at a recent march in Botswana on the 3rd of June where human rights and gender activists, and fellow women marched in the RIGHT TO WEAR WHAT I WANT walk, which aimed to highlight that no one has the right to violate another human being based on what they are wearing. Moyo argues that there is a need for an intersectional feminism that thinks about every single woman, and all the intersections of her life where oppression derives from.
The role of gender in prevention of mother-to-child transmission (PMTCT) participation under Option B+ has not been adequately studied, but it is critical for reducing losses to follow-up. This study used qualitative methods to examine the interplay of gender and individual, interpersonal, health system, and community factors that contribute to PMTCT participation in Malawi and Uganda. The authors conducted in-depth interviews with women in PMTCT, women lost to follow-up, government health workers, and stakeholders at organisations supporting PMTCT as well as focus group discussions with men. They analysed the data using thematic content analysis. The authors found many similarities in key themes across respondent groups and between the two countries. The main facilitators of PMTCT participation were knowledge of the health benefits of ART, social support, and self-efficacy. The main barriers were fear of HIV disclosure and stigma and lack of social support, male involvement, self-efficacy, and agency. Under Option B+, women learn about their HIV status and start lifelong ART on the same day, before they have a chance to talk to their husbands or families. Respondents explained that very few husbands accompanied their wives to the clinic, because they felt it was a female space and were worried that others would think their wives were controlling them. Many respondents said women fear disclosing, because they fear HIV stigma as well as the risk of divorce and loss of economic support. If women do not disclose, it is difficult for them to participate in PMTCT in secret. If they do disclose, they must abide by their husbands’ decisions about their PMTCT participation, and some husbands are unsupportive or actively discouraging. To improve PMTCT participation, the authors propose that Ministries of Health use evidence-based strategies to address HIV stigma, challenges related to disclosure, insufficient social support and male involvement, and underlying gender inequality.
South Africa has piloted a new program, 'Safe and Sound' to reduce the common risk of violence against pregnant women in South Africa. Most women were found to not speak about the violence they endure. In addition to rape and sexual violence, coercive or controlling behaviour, such as a man refusing to use a condom or restricting other forms of birth control, is argued to increase the risk of contracting HIV. Women who are HIV-positive and experience intimate partner violence are reported by the author to be half as likely to take their HIV medications as women in nonviolent relationships, leaving them in much poorer health. The author urges that countries adopt programs like Safe and Sound because violence against women, including HIV positive women, can lead to a deterioration in their mental health, with some women stopping their medication and developing suicidal tendencies.
Close-to-client community-based approaches are argued by the authors to be a low-cost way of providing basic care and social support for elderly populations in such resource-constrained settings and that family caregivers play a crucial role in that regard. However, family caregiving duties are often unpaid and their care-related economic burden is often overlooked, despite this knowledge being important in designing or scaling up effective interventions. This study, therefore, estimated the economic burden of family caregiving for the elderly in southern Ghana. It used a retrospective cross-sectional cost-of-care design in 2015 among family caregivers for elderly registered for a support group in a peri-urban district in southern Ghana. A simple random sample of 98 respondents representative of the support group members completed an interviewer-administered questionnaire. Costs were assessed over a 1-month period. Direct costs of caregiving (including out-of-pocket costs incurred on health care) as well as productivity losses (i.e. indirect cost) to caregivers were analysed. The estimated average cost of caregiving per month was US$186.18, 66% of which was a direct cost. About 78% of the family caregivers in the study reported a high level of caregiving burden with females reporting a relatively higher level than males. Further, about 87% of the family caregivers reported a high level of financial stress as a result of caregiving for their elderly relative. The study shows that support/caregiving for elderly populations imposes economic burden on families, potentially influencing the economic position of families with attendant implications for equity and future family support for such vulnerable populations.
Informal settlement upgrading is widely recognised for enhancing shelter and promoting economic development, yet its potential to improve health equity is usually overlooked. Slum upgrading is the process of delivering place-based environmental and social improvements to the urban poor, including land tenure, housing, infrastructure, employment, health services and political and social inclusion. The processes and products of slum upgrading can address multiple environmental determinants of health. This paper reviewed urban slum upgrading evaluations from cities across Asia, Africa and Latin America and found that few captured the multiple health benefits of upgrading. With the Sustainable Development Goals focused on improving well-being for billions of city-dwellers, slum upgrading should be viewed as a key strategy to promote health, equitable development and reduce climate change vulnerabilities. The authors conclude with suggestions for how slum upgrading might more explicitly capture its health benefits, such as through the use of health impact assessment and adopting an urban health in all policies framework. Urban slum upgrading must be more explicitly designed, implemented and evaluated to capture its multiple global environmental health benefits.
Out-of-pocket (OOP) health spending can potentially expose households to risk of incurring large medical bills, and this may impact on their welfare. This work investigates the effect of catastrophic OOP on the incidence and depth of poverty in Malawi. The paper is based on data that was collected from 12,271 households that were interviewed during the third Malawi integrated household survey (IHS-3). The paper considered a household to have incurred a catastrophic health expenditure if the share of health expenditure in the household's non-food expenditure was greater than a given threshold ranging between 10 and 40%. As the authors increase the threshold from 10 to 40%, they found that OOP drives between 0.73%-9.37% of households into catastrophic health expenditure. The extent by which households exceed a given threshold (mean overshoot) drops from 1.01% of expenditure to 0.08%, as the threshold increased. When OOP is accounted for in poverty estimation, an additional 0.93% of the population is considered poor and the poverty gap rises by 2.54%. The authors’ analysis suggests that people in rural areas and middle income households are at higher risk of facing catastrophic health expenditure. The authors conclude that catastrophic health expenditure increases the incidence and depth of poverty in Malawi. They call for financing measures to minimise the incidence of catastrophic health expenditure especially to the rural and middle income population.
Faced with a global threat to food security, it is perfectly possible that society will respond by reasserting co-operative traditions. This open access book, by a leading expert in urban agriculture, proposes a solution to today’s global food crisis. By contributing more to feeding themselves, it argues that cities can allow breathing space for the rural sector to convert to more organic sustainable approaches. Biel’s approach connects with current debates about agroecology and food sovereignty. It asks key questions, and proposes lines of future research. He suggests that today’s food insecurity – manifested in a regime of wildly fluctuating prices – reflects not just temporary stresses in the existing mode of production, but more profoundly the troubled process of generating a new one. He argues that the solution cannot be implemented at a merely technical or political level: the force of change can only be driven by the kind of social movements which are now daring to challenge the existing unsustainable order.
The proportion of people worldwide living in urban areas has been increasing over the past century. Southern Africa is one of the least urbanised but fastest urbanising region. The pace of urbanisation in sub-Saharan Africa is twice the global average, making it the highest in the world. The urban population annual growth rate for the region is pegged at 3.75%. South Africa and Botswana have urban populations of more than 60% and Zimbabwe 33%. The survey was conducted in 4 purposively sampled urban high density suburbs. A multi-stage random sampling was then used to select households in the 4 suburbs. The sampling frame for selecting households was obtained from ZIMSTAT, the country’s statistical office. Data was collected over a period of a week in each of the sampled suburbs. During the week the enumerators would conduct household interviews in the Enumeration Areas (EAs). Household questionnaire were used to collected data from the sampled households. The questionnaire covered: characteristics of household members; availability of and access to shelter, water and sanitation; energy sources; income sources; assets. Results shows that where the council provided the houses, the critical services were provided and water, electricity and sanitation were not an issue. The urban councils developed the properties, but their role was not clear in the new urban landscape. Issues of restitution in the event of evictions in these areas were grey areas and people did not know where to go to get assistance when evicted, to where to access legal advice. Residents wanted advice on issues to do with access to land for vending, law enforcement and women empowerment, on land tenure and how to get title deeds. Most lease agreements and title deeds were in the name of the husband, giving men more access to land for housing than women.