Throughout the 3 decades of the HIV/AIDS epidemic, responses to the virus have focused on the risks and choices taken by individuals. Prevention efforts have attempted to encourage people to abstain from sex, be faithful to 1 partner, and, when abstention is impossible, use condoms. Testing and treatment of the disease have adopted a broad-brush approach that assumes an equal ability to access and make use of health services.
The wider set of circumstances within which people take decisions has been largely neglected. Structural factors have a strong influence on the individual behavior that can heighten the risk of HIV infection and on how effectively those living with the virus cope with it. One of these factors-poverty-has begun to receive attention in recent years, with the World Health Organization's Commission on Macroeconomics and Health, highlighting the importance of the multiple links between wealth and susceptibility to diseases including HIV/AIDS.1 Examination of the links between gender and HIV/AIDS, on the other hand, has tended to take a narrow view, with men seen as perpetrators who force infection on women or carelessly pass the virus to other men, and women (with the exception of female sex workers who are frequently demonized as vectors of HIV) seen as helpless victims.
As the epidemic has progressed, the role of gender inequality in its transmission has become increasingly apparent. In the 1980s, men bore the brunt of HIV infections and deaths; today, 46% of those living with the disease worldwide are women.2 In sub-Saharan Africa, the world's hardest hit region, women account for over 60% of infections, and HIV prevalence among young women aged between 15 and 24 years is almost triple that among young men. In the Middle East and North Africa (MENA), too, where just under half of all those infected are women, prevalence among young women is higher than that among young men.3
Women are experiencing a growing burden of HIV infections in many regions, therefore, and the gender imbalance is partly responsible. Women's subordination to men both increases their risk of HIV infection and decreases their chances of survival once infected. In many cultures, for example, women lack the power to enforce condom use during sexual intercourse or to encourage their partners to present for HIV testing. Because women are twice as likely as men to contract HIV from an episode of unprotected sex, this renders them disproportionately vulnerable to infection. Once infected, women risk rejection by their families and communities, and because their access to health care is weaker than that of men, they may be less likely to survive the disease.
It is not just women who suffer from the effects of gender inequality on HIV/AIDS. Gender stereotypes can force men into behavior that heightens their risk of infection. Men are expected to have a number of female partners, for example, and in some societies it is considered unmanly to use condoms or access health care. Men's power over women, moreover, allows them to insist on unprotected sex. Unprotected heterosexual sex is the most important cause of HIV transmission, and the risk is exacerbated if an individual has multiple sexual partners. The pernicious influence of gender inequality on sexual decision-making therefore imperils all members of society.
The concept of empowerment is central to addressing the gender imbalances that allow AIDS to thrive. Until the early 1990s, the focus of international efforts to promote the advancement of poor and middle-income countries had been primarily on economic development; if a country grew richer, it was thought, its people would automatically be better off. This approach achieved only sporadic success, however. Some regions of the world grew richer, others poorer, and even in those whose overall economies grew, many sections of society saw no improvements in their quality of life. The work of the economist Amartya Sen was an attempt to address this failure. Sen adopted a “capabilities” approach to development. Seeing that individuals' freedom was constrained by the social, political, and economic opportunities available to them, he argued that the goal of development should be to expand people's capabilities so that they would be able to take control over their own lives.4,5 Empowering individuals, for example via education and health care, should go hand in hand with efforts to tackle the structural constraints that impede them from achieving their goals.
Sen saw gender inequality as the most important of these structural constraints on development: “Nothing,” he argued, “is as important today in the political economy of development as an adequate recognition of political, economic, and social participation and leadership of women.”6
Empowerment is key to rectifying the gender imbalance. Luttrell et al7 define empowerment as “a progression that helps people gain control over their own lives and increases the capacity of people to act on issues that they themselves define as important.” In the case of gender, this means both sexes having equal control of their lives. The empowerment of women can benefit all members of society. Gender parity gives both men and women increased power; although achieving it requires men to relinquish their power over women and the benefits they possess as a result of their gender, both sexes gain from this sacrifice in terms of overall quality of life improvements.
Why it Matters to the MENA
There are several reasons why gender empowerment and its links to health are important for the MENA. The region is in the midst of a dramatic demographic shift. One in every 3 people living there is between the ages of 10 and 24, a higher proportion than most other world regions.8 Although MENA countries are at different stages of the shift, the youth population (aged 15-24) of the region as a whole is expected to peak at around 100 million in 2035. This “youth bulge” has emerged at a time of increasing globalization; the movement across national borders of goods, capital, and labor is transforming economies and societies in all parts of the world.
Migration is one outcome of the confluence between gender relations, demography, and globalization that could have impacts on the region's health.
North African and Eastern Mediterranean countries have had an excess labor force for some time, but, until recently, the oil-rich Persian Gulf states have suffered labor shortages. This imbalance fostered large-scale migration within the MENA region. Because men are the main breadwinners in most families, migration of men to the Gulf by unaccompanied males has dramatically increased. These intra-MENA migrants have been joined by thousands of migrants from south and southeast Asia. Research from other regions of the world suggests that unaccompanied males migrating for work are at elevated risk for a host of health-related morbidities and can serve as a bridge for the transmission of disease to their families and communities of origin. In southern Africa, for example, migrant workers and their families have suffered disproportionately from HIV/AIDS as workers have contracted the virus from sex workers or girlfriends and transmitted it to their wives on returning home. In recent years, the Gulf States have restricted immigration to provide more jobs to their own people. Combined with strict anti-immigration policies in the European Union, this has driven migrants underground; illegal migrants are further isolated from public health services and may be more exposed to health-related vulnerabilities.
Globalization has also begun to alter cultural attitudes in the region. The Internet, the media, and foreign travel are raising young people's awareness of how life is lived elsewhere, including in more liberal societies in the west. In some parts of the MENA, this has begun to change gender norms, with women agitating for more freedom, in some cases obtaining it, and men having to adjust to a more balanced relationship with women. As gender norms change, old traditions that upheld the primacy of marriage (and the importance therein of parental approval), gave men power over women, and expected women to take sole responsibility for child rearing are under pressure. Alternate forms of “marriage,” such as common law unions and other arrangements that allow couples to have premarital sex, are becoming more widespread, and they may increase the risk of sexually transmitted infections, including HIV/AIDS. HIV/AIDS prevalence is currently low across most of the region (with the notable exception of Sudan), but surveillance is not strong so there can be little certainty over the direction the virus is taking. Opening up to the world in a healthful way will be important to the region's future success and will have large impacts on the quality of life of both men and women. As we discuss in the Section “Gender, Empowerment, and Health,” gender equality is essential for strengthening health and avoiding health risks.
Preparing the region's burgeoning youth population for meaningful participation in the global community will be impossible without effective education that is tailored to the demands of the modern world. Although the MENA have achieved much in narrowing the enrollment gap between boys and girls in schools, these young people have not been equipped with the skills needed to prosper in today's global economy-unemployment rates across the region remain alarmingly high. Effective education is not just limited to the provision of information; rather, it should be responsive to a country's development needs. Education, as we discuss in the Section “Closing the Gender Gap,” has a major role to play in reducing gender disparities, particularly if it is designed to break down long-established gender prejudices; it should also be seen as providing both women and men-empowering them-with the skills and knowledge needed to thrive in the modern world.
In the next section of this article, we show how gender influences the health of men and women. In the Section “Closing the Gender Gap,” we discuss the economic, educational, social, and political factors that can promote empowerment and improve health and, in particular, help tackle HIV/AIDS. The concluding section makes recommendations for action that can trigger gender empowerment and thereby strengthen health.
GENDER, EMPOWERMENT, AND HEALTH
How Gender Affects Health
In most societies, including those in the MENA, women are disempowered relative to men. Men generally earn more than women, own more than women, are better educated, and dominate community and national institutions. Over many centuries, a gender imbalance has developed that gives men more freedom to control their lives than women and often also gives them the freedom to control women's lives.
This gender imbalance harms the health of both women and men. For women, the resultant health threats can begin in the womb. In some societies, a cultural and economic preference for boys has encouraged the growth of sex-selective abortion, with new screening technologies allowing female embryos to be identified and aborted. Millions of women are “missing” as a consequence.9
The threats that result from women's disempowerment continue during childhood. Gender stereotypes mean boys are seen as needing to be physically strong. Their survival, moreover, is more valuable to their parents than that of girls because as adults they will earn money that will support their family, whereas girls in many cultures impose costs on parents through dowry payments. In families where resources are scarce, therefore, girls are often fed less than boys. This weakens their bodies and makes them more vulnerable to illness; worldwide, girls and women lose more Disability Adjusted Life Years (DALYS) than men to nutritional disorders and conditions related to muscle and bone strength.10 Because of the imperative to equip boys for the workplace, moreover, girls receive less education than boys, which gives them a lower awareness of how to protect themselves and their families against health threats. Girls also receive less health care than boys; in both rich and poor countries, girls and women fall ill more often than men.11
In adulthood, women's disempowerment exposes them to new health threats. In many cultures, women are objectified by their partners, families, and communities. They are seen as child bearers and given little control over sexual intercourse or fertility choices. Unable to insist that their partners use contraception, they are exposed to sexually transmitted diseases, including HIV/AIDS. They are often forced into having abortions, many of which are carried out in unsafe conditions. Abortion not only causes stress; the procedure kills 70,000 women each year.12 When they do give birth, inadequate investment in women's health means that obstetric and maternal care are often lacking; more than 500,000 women die during or as a result of childbirth every year, with many more suffering illness or disability.13 Globally, women lose many more DALYs to health problems associated with reproduction than men.10
Men's power over women is enforced in many societies by violence. Violence against women is either ignored or condoned as a means of keeping them in their place. Domestic violence is underreported in all countries, but in 50 population-based surveys in a wide range of countries, between 10% and 50% of women who had had sexual partners reported being physically assaulted by a male partner.14 Such violence, of course, can lead to deterioration in mental and physical health.
Sexual violence is a further threat. Most vulnerable to this are sex workers, who regularly fall victim to assault, rape, and sometimes murder at the hands of clients, their bosses, or the police. Women and girls who are not involved in the sex work industry are also at risk. Sexual violence, including rape (both marital and non-marital) and coerced sex, poses much more of a threat to females than males; in a review of studies of childhood sexual abuse, most reported that girls were much more likely to be the victims of sexual violence than boys.15 As discussed below, sexual violence exposes women to sexually transmitted infections, including HIV/AIDS.
Repression of women does not just harm their physical health. Worldwide, women are over twice as likely as men to suffer from depression.16 In the MENA, several studies found that the vast majority of suicides or attempted suicides in Iran were committed by women, usually as a result of quarrels with partners or families.17
As well as being more likely to become ill than men, women are also less likely to be cured. Women have weaker access to health services than men; in many countries, they need men's permission even to visit a health care facility.18 Health systems, moreover, are designed and run by men, and senior health staff are predominantly male. Women are, therefore, often poorly treated in health facilities which, as the high rates of maternal mortality and unsafe abortion in some countries show, are not always tailored to their needs and sometimes pose dangers to them.19 According to the World Health Organization, tens of thousands of women are sexually assaulted in health care facilities each year.20 Research into women's health problems is also often less concerted than for illnesses that primarily affect men, meaning that remedies for their health problems are thinner on the ground, even where they can access health services.21
Men's health also suffers from gender inequality. Men in most societies are expected to be macho and physical. Men are usually on the frontlines in dangerous professions such as the military and police and they are more often involved in fights. Many more men than women are killed or injured each year as a result of fighting, crime, and warfare.22
Gender stereotypes also encourage men, and particularly young men, to take risks, whereas women are expected to be cautious. Globally, men drink and smoke more than women, eat less healthy food, and drive more dangerously.23 Men lose many more DALYs each year than women as a result of illnesses related to consumption of alcohol, smoking, drugs, and unhealthy food, and many more are killed or disabled in road and traffic accidents.24
This risk-taking stereotype leads men to pay less attention to their health than women. There is evidence that men delay seeking health care for fear of being seen as unmanly.25 Men's cavalier attitude to health means their illnesses progress further before they eventually seek treatment, which increases the likelihood of an unsuccessful outcome.
The disempowerment of women is a further threat to men's health. Women are traditionally the gatekeepers of family health. Healthy mothers and wives are better able to look after the health of husbands, sons, and daughters. Women armed with strong knowledge of health-seeking behavior can transmit that knowledge to their families, and women with power and respect within families and communities can lobby for resources to be invested in health care. Women's lack of power within the household and their lack of influence on national policy-making mean both women and men receive less, and less effective, healthcare.
How Gender Affects HIV/AIDS
Many of the gender norms that harm women's and men's overall health also heighten their risk of contracting HIV/AIDS. Just as women are more likely to suffer ill health overall than men, they are also increasingly likely to contract HIV/AIDS. Worldwide, young women's risk of being infected is 50% higher than that of young men. Women's share of people living with HIV/AIDS rose from 41% of adults in 1998 to almost 50% in 2005.26
Many of the channels that lead from women's disempowerment to an increased risk of HIV/AIDS are not dissimilar to those that imperil their overall health. If girls are fed less than boys during childhood, malnutrition weakens their bodies and their immune systems and the effects of this can endure into adulthood. Denying girls access to health care has a similar effect, rendering illnesses such as HIV/AIDS more difficult to fend off.
Girls' weaker access to education exacerbates their vulnerability to HIV. Girls' enrollment in school is lower than that of boys, and around the world, numerous studies have shown that girls know less about HIV/AIDS than boys.27 The education gap can also make girls and women less confident in discussing the risks with men and, therefore, less empowered to discourage their partners from risky behavior such as having multiple partners or refusing to wear condoms during sex.
A lack of education combines with traditions that encourage women to take responsibility for unpaid domestic work to disempower women economically. Worldwide, men own over 85% of land, and they dominate labor markets and earnings across the globe.28 Women's lack of economic power means they are less able than men to pay for and access protection and treatment for HIV/AIDS. They are also more likely than men to be forced by poverty into sex work or into performing sexual favors in return for money or food. Because they involve multiple partnering and often also unprotected sex, these activities greatly increase the risk of HIV infection.
Women's vulnerability to violence at the hands of men poses a further threat. Violent sexual intercourse makes it biologically easier for the HIV virus to be transmitted from men to women, and particularly to girls.20 Sexual abuse during childhood leaves long-term sequelae; a study in Barbados found that women who had been abused as children had a higher number of sexual partners in adulthood, whereas men who had been abused were less likely to use condoms.29 The World Health Organization has found that women who had been sexually attacked by male partners had a higher risk of contracting a sexually transmitted infection.20 Violence and the threat of violence make it more difficult for women to refuse unprotected sex or to leave relationships that put them at risk of HIV infection. A study of 1366 South African women found that those who had been beaten or were dominated by their male partners had a 48% higher risk of HIV infection than those whose partners were not violent.30 In Tanzania, meanwhile, HIV-positive women were over twice as likely to have been attacked by their partners as HIV-negative women.31
Women who are infected with HIV/AIDS can face barriers in accessing testing and treatment because of their gender. As discussed above, girls and women generally have weaker access to health care than men, and AIDS testing and care is no exception. There is a high degree of stigma surrounding HIV/AIDS; women who become infected, unlike men, are often seen as having been promiscuous and as having contravened the chaste stereotype their gender has forced on them. Many women are therefore reluctant to attend testing centers, for fear of opprobrium among the family and community, or to begin treatment, for fear of violence at the hands of partners.
The burden of care for those infected with HIV/AIDS falls heavily on women. Mothers and daughters in most societies bear the primary responsibility for family health, and caring for people living with HIV/AIDS adds to women's workload and increases their stress levels. This can result in a vicious circle, whereby an HIV infection in the family imposes additional responsibilities on women who therefore have less time to earn a wage or become educated and are therefore less able to avoid ill health themselves. Even when men and boys believe that they should contribute to caring for the sick, gender norms often stop them as such duties are seen as “women's work.”32
As with broader health problems, gender norms render men, too, more vulnerable to HIV/AIDS. For example, the expectation that men should have many sexual partners increases the risk that they will have intercourse with people who are HIV positive. Having multiple sexual partners is a prime risk factor for HIV infection.
Men's violence increases their own risk of HIV infection as well as that of women. Men who hold traditional views about masculinity are more likely to have used violence against a female partner and are more likely to have contracted a sexually transmitted disease.33 Partly because of their use of violence, men experience much higher rates of incarceration in prisons than women. Prisons are a fertile environment for HIV infection-male-on-male rape and consensual sexual relations between men heighten the risks of transmission. In Tripoli, Libya, for example, HIV prevalence rates of 18% have been recorded in prisons.2 The shame imposed by gender stereotypes, moreover, makes men reluctant to report male-on-male rape, making it more likely that a sexually transmitted infection will go untreated.34
The expectation that men will take risks makes them less likely to use condoms during sex. A study in Brazil found that young men with inequitable gender attitudes were less likely to have used condoms the last time they had sex with their primary partners.35 The propensity to take risks also makes men more likely to inject drugs than women. Injecting drug use is a major conduit for HIV; in the MENA region, it is the main transmission route in Afghanistan, Iran, Libya, and Tunisia.2 Alcohol abuse, too, which is more prevalent among men than women, increases the risk of contracting HIV because it makes gender-based violence more likely and makes people less cautious during sexual intercourse.36
Men's carefree attitude to their health also extends to HIV/AIDS. Men in some cultures believe that it is weak to seek health care, and studies in South Africa have found that women, despite the constraints outlined above, account for the majority of those presenting for HIV counseling and testing.37,38 Being tested and put on treatment early is a vital predictor of the effectiveness of antiretroviral therapy for HIV/AIDS, so men's delay in accessing such services imperils their survival.
Finally, women's role as gatekeepers of family health is harder to fulfill if they are debilitated by AIDS, and this has impacts on men and boys and girls. As the virus becomes feminized and increasing numbers of women fall sick, their ability to care for their families is impaired. As more women die, men will be left to care for families and men infected with the virus will have nobody to attend to their treatment and care needs. The gender stereotypes that place women in the role of health gatekeepers therefore combine with growing HIV prevalence rates among women to leave entire families with reduced hopes of surviving the disease.
CLOSING THE GENDER GAP
Not all countries suffer from stark gender inequality. Many have succeeded in strengthening women's status relative to men, and the health of both has improved as a consequence. Action in 4 key areas seems crucial to reaping the health benefits of increased gender parity.
Globally, and also in the MENA region, men have much greater economic power than women. As well as owning the vast majority of land, they earn approximately one-third more than women for the same work.39 Women are much more likely to work in the informal sector than men, and they also bear most of the burden of domestic duties for which they are generally unpaid. In the MENA, where women comprise 49% of the overall population, they account for just 32% of the labor force, a much lower proportion than in the rest of the world.40
Empowering women economically can have significant benefits for the health of both women and men. It can also reduce their risk of HIV/AIDS infection and make the virus less difficult to cope with.
The links between wealth and health are well established. Financial resources enable individuals to protect themselves against health threats by eating better food, drinking clean water, living in safer environments, accessing sanitation facilities, and arming themselves with the knowledge to fend off health threats. If wealthier people do fall sick, they can more easily afford effective health care and they are more likely to have access to strong social support networks. Wealthier people also tend to have fewer children, meaning they can invest more resources in protecting the health of each child. The World Health Organization has estimated that people living in absolute poverty (that is, earning less than $1 per day) are 5 times more likely than those who are not poor to die before the age of 5 and two and a half times more likely to die between the ages of 15 and 59.41
Women who lack financial resources are less able to take control of their health; as a study in Zambia found, for example, men within families were more likely to receive medication for illness than their wives because women could not afford to pay.42 Conversely, if women work outside the home or own property, they have more respect within the family because they contribute to its finances and therefore more voice in decision-making.43 In their role as gatekeepers of families' health, greater power over family decision-making can enable women to lobby for increased resources to be devoted to their health and that of their daughters, sons, and husbands.
Men's health benefits in other ways too. Women's economic empowerment eases the burden on men of having to support their families financially. Many men struggle to cope psychologically with losing their jobs or with a sudden decline in income, often turning to risky behaviors such as alcohol or drug consumption or becoming depressed as their families slide into poverty and they see themselves as not having fulfilled their gender role.44 Women who earn an income of their own have the potential to lighten the financial load on their male partners, thereby improving the latter's mental and physical health, while having 2 breadwinners has the added benefit of making it easier to bear treatment costs when family members fall ill.
Women's increased wealth can also protect them and their families against HIV/AIDS. Wealth is associated with greater knowledge about the benefits of condom use45 and a greater awareness of the risks of HIV infection.46 A study in Los Angeles found that couples where women were economically independent from their partners were more likely to use condoms than couples where women were dependent.47 Economically independent women are also better able to negotiate safe sex with their partners and to leave relationships that put them at risk of HIV infection.48 All these factors can translate into reduced HIV transmission; a large study in South Africa found that women who were not financially or emotionally subservient to their partners had a 52% lower infection rate than women who were dominated.30
Wealth, of course, increases one's prospects of receiving a good education. Education, in turn, can empower women and improve their health, thereby giving both women and men greater control over their lives.
There are large discrepancies between women's education and men's education worldwide, with boys in most countries receiving more years of schooling than girls. The MENA have made great strides in narrowing the gender gap in education in recent years, but enrollment and completion ratios remain lower for girls than boys in both primary and secondary school, and countries such as Yemen, Iraq, and Turkey have much higher enrollment among boys than girls at secondary level.49 In Egypt, even women favor boys' education; if they could only send 1 child to university, 39% of women who responded to the 2000 Demographic and Health Survey would prefer their son to attend rather than their daughter, with only 8% preferring their daughter to go (53% said the children's abilities should be the deciding factor).50
Strengthening girls' education can have profound impacts on their health and that of society as a whole. Girls who attend school have access to information on hygiene, nutrition, and disease, and in many countries, schools provide them with vaccines and nutritious meals. Educated girls earn more in adulthood, which gives them the resources to protect themselves against health threats. And educated mothers are better able to defend the health of their (male and female) children.
A wealth of research has demonstrated strong links between girls' education and health. Schooling is associated with lower blood pressure, reduced obesity, and a lower risk of disability, and it reduces mortality among adults.51,52 Mothers' education reduces the incidence of low birth weight and premature birth among their children.53 Their health knowledge strengthens their children's health54; each year a mother spends in primary school reduces her children's risk of dying before their fifth birthday by 8%.55 In Egypt, the child mortality rate among families where the mother had had no education was 89 per 1000 live births compared with just 38 per 1000 live births in families where mothers had completed secondary schooling.56 According to Amartya Sen, female literacy is a more important determinant of child mortality than male literacy and poverty reduction.57
Women's education can also limit the spread of HIV/AIDS. Where disparities between male and female literacy are high, the risk of a widespread HIV/AIDS epidemic is accentuated. A 72-city study by Over58 found significantly higher infection rates in those cities where the literacy gap was larger, whereas another found that a literacy gap of more than 25% between boys and girls increased the likelihood of a generalized HIV/AIDS epidemic.59
Worldwide, UNAIDS reports that women currently know less about HIV transmission than men.60 Education gives women the know-how to protect themselves against the unsafe sex that leads to infection. By strengthening their knowledge and empowering them economically, it gives them the confidence and the negotiating skills to advocate for safer sex with their partners. The education of both girls and boys, meanwhile, can help break down the stigma surrounding AIDS, which makes it easier to discuss the virus, present for HIV testing and access treatment.
Girls who are educated can avoid many of the key risk factors for HIV infection. Studies in sub-Saharan Africa found that women who had received at least 8 years of schooling were much less likely than those who had not attended school to have had sex before the age of 1861; in Egypt, women who have completed secondary education have a wider knowledge of contraceptive methods than those with primary education62; and research in 17 developing countries found that better educated girls more often insisted that their partners use condoms during sex.63 The World Health Organization has found that educated young women are less vulnerable to intimate partner violence-a risk factor for HIV infection-than uneducated women; they are also more easily able to leave violent relationships.64
A further aspect of empowerment that can improve women's health and men's health relates to the social and political spheres. Engagement in society is a powerful driver of improved health; exclusion from it is a strong predictor of depression. “Social capital” refers to the connections and networks among individuals and the “norms of reciprocity and trustworthiness that arise from them.”65 Such networks enable societies to work together to fend off health problems and provide support to those who are sick. Being plugged into such networks can give individuals advance warning of impending health threats, information on how to avoid them, and when they fall sick, access to assistance and emotional support during treatment.
According to the political scientist Putnam,65 “people whose lives are rich in social capital cope better with traumas and fight illness more effectively.” People who are well connected to their communities face a lower risk of heart disease, cancer, depression, and many other illnesses. A number of large studies show that those who are socially disconnected face at least double the risk of dying from any cause compared with those who have strong familial and community relations.66
Women in many countries have weaker access to social capital than men. In parts of the MENA, for example, women are expected to spend most of their lives at home and their networks are limited to their close family. Some have to seek their male partners' or relatives' permission to leave the home. Transgender individuals, too, face social exclusion in many societies.
These constraints imperil health; self-help support groups, for example, have been found to improve the mental and physical health of those who join them, but these benefits are not available to isolated women.67 They also have effects on HIV/AIDS transmission and treatment. Because it implies isolation from nonfamily support networks and from police services, social exclusion renders women more vulnerable to violence, a risk factor for HIV. Not having heard about HIV prevention and treatment services, which is more likely among those who are not connected to social networks (and those who are not educated), is a predictor of decreased use.68 Social support, including help with negotiating health care systems as well as emotional succour, “is one of the most consistent predictors of better HIV medical adherence, virologic outcomes, and reduced morbidity and mortality.”69 A study of HIV-positive injecting drug users in the United States found that those who had social support were 4.6 times more likely to record successful treatment outcomes after 12 months than those who lacked such support.69 Those HIV-positive individuals who are connected to social networks also report improved psychological well-being compared with those who are more isolated.70
An absence of social capital also makes it more difficult for women to mobilize politically to improve a society's health. Women who are confined to their homes cannot join with other women to advocate for improved medical services, for example, or to claim their existing rights.
Political empowerment-“the capacity to analyse, organize and mobilize”7-is linked to human rights. The Universal Declaration of Human Rights in 1948 stated that everyone “has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care, and necessary social services,” and successful advocacy by women's groups has led to a series of conventions and declarations on women's right to health, which in recent years have also covered HIV/AIDS. The 1979 Convention on the Elimination of All Forms of Discrimination against Women requires states to eliminate discrimination against women in the field of health care and provide them with equitable access to health care services, including family planning. The Vienna Declaration of the World Conference on Human Rights in 1993 recognized the importance of women's right to health, and a year later the International Conference on Population and Development, held in Cairo, set out recommendations for addressing women's vulnerability to HIV/AIDS through reproductive health services.
Across the world, this political mobilization by women has contributed to huge improvements in health and overall quality of life. It has led to the expansion of family planning services that have allowed women greater choice over fertility and better protection against sexually transmitted diseases. Declines in fertility have given countries a “demographic dividend” whereby smaller numbers of young dependents have allowed working adults to invest more time and resources in economic activity, with large benefits to economies.71 Legalization of abortion in many countries has sharply reduced abortion-related mortality and morbidity. Lobbying by women's groups and female politicians has moved diseases that affect women, such as breast and cervical cancer, closer to the center of health policy and research; the consequent advances in prevention and treatment technologies have saved millions of lives and averted untold anguish among both women and men. Activism by disempowered groups such as sex workers and men who have sex with men has enabled them to garner acceptance in some societies and lay claim to their rights. Social inclusion, as the success of men's groups in California in reducing HIV transmission in the 1980s and 1990s shows, has improved their health.
Progress in the MENA has been slow, however. Although many countries have signed up to international agreements, women are politically disempowered and routinely denied their rights. Women make up just 3.5% of members of parliament in Arab countries, and only sub-Saharan Africa has lower female participation in political life.71 According to Human Rights Watch, “family, penal, and citizenship laws throughout the region relegate women to a subordinate status compared with their male counterparts.”72 Partly, as a consequence of this weakness, laws prohibiting violence against women, including rape, sexual coercion, and battering, are either absent or unenforced. Domestic migrant workers, who are mainly women, are excluded from national labor codes, and the human rights of women who are trafficked into the region's sex industries from Eastern Europe and Asia are often neglected.
There are some signs of a growing realization in the region of the importance to health of women's social and political empowerment. In December 2004, 80 influential religious leaders from 19 Arab countries met in Cairo to discuss the threat of HIV/AIDS. The Cairo Declaration of Religious Leaders in the Arab States in Response to the HIV/AIDS Epidemic included recognition of “the rights of women to reduce their vulnerability to HIV/AIDS” and a call for the protection of the human rights of those living with the virus.73 Although this recognition by a traditionally conservative group is a promising step, only when women are more strongly represented in political bodies will they be able to shape institutions and laws to benefit the whole of society.
AREAS FOR ACTION
Focusing on the 4 key areas of empowerment outlined below will pay dividends for the MENA.
Promoting Economic Empowerment
In the realm of economic empowerment, it is essential to increase women's participation in the workplace. Laws to prevent discrimination in recruitment, pay, and promotion decisions will have some impact if enforced, but there is also a need to make the workplace more attractive for women. Stricter observance of sexual harassment legislation and rules prohibiting violence against women is needed, with a particular focus on protecting sex workers and domestic workers, who are most vulnerable to abuse.
Laws by themselves are insufficient, however. Efforts must be made to change societal norms that place women at home and men in the workplace. Involving men in discussions on the benefits of women's work should go hand in hand with encouraging men to share caring duties, perhaps by promoting paternity leave policies. Cheap day care for children can assist both men's and women's participation in work. Economic assistance and actions to protect the mental and physical health of men who have become unemployed or experienced sudden income loss-a particularly vulnerable group-will benefit families where men are the main breadwinners. Microfinance programs, meanwhile, can give a kick start to women who are unable to find work in the formal sector; such initiatives have been found to have major benefits for family health, including HIV/AIDS prevention.74,75
It is important to recognize the economic impacts of ill health on women. Bringing health care into communities-in the case of HIV/AIDS, for example, voluntary counseling and testing, family planning services, and antiretroviral drug provision-can reduce the time women have to take off from domestic duties to access services and cut transport costs. Financial support and supplies for women carers would compensate them for relieving the burden on public health services. Poverty reduction efforts aimed at women, moreover, should incorporate health care, because poor health is a major constraint on those attempting to climb the economic ladder and can therefore render programs to tackle poverty ineffective.
Promoting Educational Empowerment
The MENA region has made significant progress in expanding girls' education, but dropout rates remain higher than for boys, and greater efforts must be made to ensure that girls complete schooling. Every year counts in terms of its impact on women's empowerment and on health, so addressing the barriers to girls' schooling, including familial resistance, the cost of education, and withdrawal due to early pregnancy, is crucial.
Education on health issues including HIV/AIDS can also be beneficial. Since AIDS education began in Ugandan schools, the proportion of students between the ages of 13 and 16 who were sexually active has plummeted from 60% to below 5%.76 Such education should emphasize to both girls and boys the importance of gender equality and the damage done by violence against women.
Education does not finish on leaving school. Educating adult men on the benefits of gender equality has made a large impact in some countries; showing men that they can be agents of change and that all members of society can benefit from gender equality is a vital step toward transforming gender relations and improving health. In Nicaragua, for example, workshops for men on gender equality and masculinity have resulted in reduced intimate partner violence, increased participation by men in domestic duties, including caring, and more shared decision-making by couples.77 In the HIV/AIDS sphere, initiatives such as “Stepping Stones,” which has been used in over 40 countries, bring men and women together to discuss gender, health, and HIV/AIDS issues and how they are important for the well-being of all. In South Africa, the program has helped reduce violence against women, made men's attitudes toward women more equitable, and by promoting increased condom use and reductions in individuals' numbers of sexual partners, helped reduce sexually transmitted infections in women.78 In addition, voluntary counseling and testing of couples for HIV/AIDS can encourage people to take joint responsibility for their sexual decisions and, if testing reveals HIV infection, for their treatment and care.
Gender sensitization for people who work in health care settings is also important. Inculcating respect for women among health professionals, including by enforcing strict rules against abuse; integrating responses to violence against women into HIV/AIDS programs; training health workers to recognize signs of violence; and providing training to domestic carers are among the most pressing measures.79
Promoting Social Empowerment
Increased social capital is vital if women in the MENA region are to agitate for gender equality.
Women's groups have been at the heart of similar efforts elsewhere, and these groups should be encouraged, including with funding support. Gender empowerment is a broad issue with broad benefits to society, so women should look to link up with activists in other fields to develop a holistic response to the problem. Bringing men and women together for joint learning and advocacy, for example, has shown promise in other regions, and human rights groups also have much to offer in assisting women in claiming their rights. Cooperative efforts by marginalized communities such as sex workers, meanwhile, can both promote women's empowerment and improve health; the Veshya Anyay Mukti Parishad (VAMP) group in India, a sex worker collective that conducts peer education programs, distributes condoms, helps women access health care, and attempts to resolve disputes with authorities, has helped increase condom use among sex workers' clients and reduce police raids on brothels.80
Health services can play a role in promoting social capital if structures are created to encourage civic participation in their management.81 As well as giving people more say in how society is run, this can make services more responsive to individuals' needs and therefore more cost efficient. Once the structures are in place, efforts will be required to reach out and encourage participation. Because the region's women lack power relative to men, special efforts will be needed to bring them into the fold.
Despite efforts to promote the social capital of women, some will inevitably slip through the net. The health of poor and marginalized women is most at risk, and outreach to isolated women by health workers should be a priority. It should include counseling on intimate partner violence and provision of HIV/AIDS services to those who would otherwise be unable to access them.
Promoting Political Empowerment
The above actions aimed at strengthening social capital are likely also to promote the political empowerment of women and other hitherto underrepresented groups.
Beyond these measures, education is a further necessary step. Teaching girls and boys in school about human rights, including women's rights, is a relatively easy win on the road to gender parity. The importance of sexual and reproductive rights, both for health and overall gender equality, should also be emphasized. Nongovernmental organizations with expertise in rights could assist in such teaching and should also encourage more women to become politically active, perhaps via mentoring schemes or outreach work by women who are already involved in the political sphere.
Appropriate education and training will prepare women to mobilize politically and to have greater involvement in policy-making, but political institutions must also become more welcoming to them. Political parties in developed countries such as the United Kingdom have used affirmative action-all women shortlists for elections, for example, and targets for female members-to increase women's participation. Similar tactics could benefit public sector institutions, including the health care sector, in the MENA. Where affirmative action is difficult, the public sector should, at a minimum, insist on nondiscrimination in hiring, pay and promotion, while making active efforts to encourage women to apply for jobs.
The MENA has the opportunity to open up to the world in a healthful way, and increased gender equality is essential to strengthening health and averting risks. The region's governments have recognized this by signing up to the United Nations Millennium Development Goals, which commit to “promoting gender equality and empowering women” and “improving maternal health”.82 It is now time for them to deliver.
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