Public Health Mitters

diseases that often accompany infection. spread uf infection. The women in communi- they thought ahout possibihiies of preventing Thus, prcventton has to be the focus itt public ties such as the ones we visited are neither infection, and how the\ perceived their sexu- health tnessages. Although breasl-feeding is unaware nor passive. They are ready to ex- ality in response to the nsk. We also asked now known to transmit the \ irus fn>m mother press their \ lews and ready to mobtlize to people whether the> had seen or used either a to child, the dilemma inxolvcd in distuurag- achieve realistic goals. male or a temale condom ing breast-feeding and thus subjecting tnfants .Mthough the focus of the research was to the nsks of fatal gastri)cntcntis ur sU)r\a- not use ofthe female condom, our interviews tion has yet to be addressed on a community- Field Sites were open-ended, and as it ttimed out. the re- wide level among poor populations. Never- actions of women respondents frequently theless. pre\enli\c messages fotuMnt; on Tlic field obser\ations were camed oul brought this method to the forefront ofthe "one partner" and "love taithfully." the com- by the first author (IS ). joined by Eleanor discussion Nevertheless, the discussions did promise solution frequently adopted by gov- Preston-Uh\1e and Quarraisha Kanm on the not alwavs take the same form, and certainly ernments in southem Africa and elsewhere, South Atncdn \isits. Richard Lee on all the both the level and the nature of the response overlook the reahties of lile for many. visits in Namibia and Bots"wana. and Karen differed widelv from site to site, a point to The broader sociai context^whieh in- Brotlkin in Namibia in 1V*J7. which we return in the conclusion. cludes widespread po\erty and unemploy- The research at the 2 sites in Durban. ment, particularly among women, a history South Atnca, wxs part ofa larger communitv Agrtctilturul I illage Outside Durban. of men's crossing national boundiines in bat- education project dealing with Hl\' AIDS, South.Africa (IW) tles for independence or other military ac- with ongoing evaluation both through ques- tions; social disasters, and the increase in tionnaires and through participants' com- The first visit was to a rural village, intra-Africa economic exchanges, which are ments about communitv groups jnd politi- scattered over a series ot hills, and was a based on colonial patterns of production rein- cal avenues ol representation tor men and 3-hour bus nde from Durb;ui. It was. in 1992. forced by une\en regional investment in the women. In IW2, with the participation ot' part o\ the area designated to the control of global economy—is heavily incnmmated in Z.S-. observations were conducted in an agn- the Zulu king Both men .ind women went to the spread of HIV AIDS in Afnca. Ad\ice to cultural village outside Durban and an infor- Durban lor work However, transportation be monogamous is hardly likely to be heeded mal scniement on the out>kirLs of Durban In > expensive and difficult, und the common in such circumstances.'" has been 1945, tJeanor Preston-Whyte and IS. re- pattern was tor men to go to town for the the rule in many Afhcan societies and is siiil turned to the lntormal settlement to follow up week and return on weekends Most ofthe common in many. In addition, the involun- on the research ol" 1W2 (The agncultural vil- wumen panicipated m a communal garden- tary migration associated with men's employ- lage could not be revisited at that time be- ing proiect 3 davs a week when the imgation ment away from home, experienced by al- cause It was the site of intense political vio- was tumed on .-Mthough the women eamed most all families in rural and semirural areas, lence ) We conducted 3 public meetings with some monev bv seMint: truit. vegetables, and is associated almost inevitably with casual women v\ho had participated in the onginal old clothes and through child care and do- and extramarital encounters, and not only for communit\' educatitm efforts. mestic work. man\ rehed on men for cash the men. As a result of all these factors, extra- The research m Namibia was conducted contributions." At the time ot the initial field- marital sex is frequent among men and with Richard Lee as part ofa larger project work, laundrv and bathing were done in the widely tolerated, if not enjoyed, by women. thai was concerned with training students nver at the bottom ot a hot, dusty hill upon This statement is derned from comments from the University of Namibia in anthropcv which the mud and a^hbrick homes were made both on formal questionnaires and m logical research vMth respect to Ml\' .AIDS. buill. and dnnking water v\as carried up by focus groups. In 1996 we interviewed informants in the women und children trom the same source. There is at least one sad circumstance Ovanibo-speaking region Okavango. In In 1991 and 19^*2 a public works pro)ect was that favors preventive behavior: as people ob- 1997, with Karen Brodkin. we conducted instituted that inlriHluccd electricity and run- serve the deaths of family members, infants. similar interviews and obsenations in Rundu ning water to the v illage. and neighbors infected with HIV AIDS, their along the Okavaiigo River In |99hand 1999. Residents were represented at civic awareness of their own risk becnmes more Richard Lee and IS conducted interviews eouncil meetings, ,ind m 14*^)2, all civic coun- firmly intemah/ed. Although this awareness along the border between Namibia and cil members were men. All members ofthe occurs rather late in the epidemic, it is a stim- Botswana, the ht>me ofthe Ju 'hoansi. a tribal court were men. and niunv of these ulus for women to lake action and search, Bushman peuple living in the Kalahari were the same men who reprcsenled the vil- sometimes desperately, for steps they can Desert. At each site, we were accompanied lage m Afncan National t ongress (.ANC) re- take, individually or collectively, to protect by translators who were familiar with the ;irea gional meetings Although there were I20or- themselves and their community. This was as well as the language. gani/atiuns umoiig the .ippro\inutcly lUlKX) certainly a phenomenon we observed during The research at each otthe 3 sites in Na- residents, women did not often speak pub- our visits. mibia included interviews with health care licly Iield rcse;irchers reported that in 1992 Two points emerge from this analysis, providers und olher institutional rcprc^cnta- women were not expected to speak up in and they were validated in our work. First, iives, such as church otlicers, teachers, and front of men m this rural community, which under the threat ofthe AIDS epidemic, see- representatives of local and international was under the control ofthe largely male ing kin and neighbors succumb and know ing nongovernmental organizations We also hereditiiry chictdoms- these victims are no ditTcrent from them- talked with both men and women at public Through answers to our questionnaires selves, women ure demanding methods ot meetings and m their homes. Although our and thrt)ugh ihc public discussions we ob- prevention and arc willing to use them. Sec- inquiries and discussions on each occasion served uutsidc one clinic, it became clear that ond there are approaches that informed com- were informal, when talking with women AIDS was assoeiated with witchcraft and munities can develop cnllectively both to care alone or with mixed groups we did ask ques- wilh the disease that, according to folklore, a for those infected and to limit the further tions about their understanding of HIV, what man contracts il he sleeps w ith another man's

July 2000. Vol. 90, No. 7 Amencan Joumal of Public Health 1043 Public Hralth Matters

settlement was to provide work for women. with them-they had seen coverage ofthe partner At the meetings held by researchers They requested that the project consider nots on CNN. They were exposed to a wide outside the clinic, the v\omen scarcelv spoke; funding a candle-making factory. They variety of topics through the international the tew men on the periphery ofthe group of pointed out that since there was no eleetncity media Thus, in general, people in the infor- women actually attending the clinic were in the settlement, this would be an extremely mal settlements were aware of HIV and much more vocal than the vvomen A survey profitable concern. of 200 households in the village indicated other issues When asked if they would use the fe- that the v^omen did not know how to identify The researchers made contact with the male condom, the women became enthusias- sexually transmitted diseases or the names of community through a sewing cooperative or- tic. They said that they would definitely use any such diseases In contrast, the men were ganized by and for local women, ks noted very well informed. above, this cooperative had also worked to something like that, over which the woman had control. They asked when the female It appeared difficult, in this setting, to bring water to the community. They had condom might be available and asked that the involve vvomen in meetings and for vvomen to begun to weave baskets for sale and were researchers provide them samples as soon as negotiate safe sex with men or e\en to talk concemed with developing ways to tie into about their OWTI health issues.' the informal economy, possible. In terms of discussion of sexuality and Thus, only a few miles removed from Informal Settlement on the Outskirts of HIV infection, the women in this cooperative their previous existence in the rural areas, Durban (1992. 1995) presented a contrast to the women in the rural women's expenences and their perspectives community In a W42 meeting, members of on sexuality—as well as their willingness to The informal settlement north of Dur- the research team discussed HI\' with about speak in public—were dramatically altered. ban consisted of about 5000 homes inhab- 50 women and 3 or 4 men Even before the ited by an estimated 3(J000 people. This meeting started the riwm was in an uproar— population had only begun to move to the the local community organizer, a woman, had area after the pass laws that restncted .Afri- brought in copies ofthe ANC constitution, When asked if they would can residence in urban areas vvere revoked. nevsly translated into Zulu. The transition In 1992 the area had no sanitation, running from \\ hite domination of South Africa to a use the female condom the water, or public services such as garbage multiracial government was about to take women became enthusiastic. eolleetion. roads, or lighting. People walked place (In 19^4. South Afnca held its first and drove along winding, dusty. narrov\. and multiracial eleetion. and the ANC won by an precipitous paths As a result ofthe efforts of overwhelming margin.) the women's community organization. Dr Nkosasana Zuma. who later became 7 faucets had been built in scattered loca- the Minister of Health (1994-1999). was a In 1995. Eleanor Preston-Whyte and tions around the settlement. People could member ofthe research team at the time and IS. returned to the informal settlement with collect water for use in their households the ANC representative from the area. She the community liaison person from the 1992 from these faucets. spoke to the group in Zulu about the impor- project. At the meetmg convened by the liai- Children had to travel to neighboring tance of HI\' and the need for women to pro- son person, we found that the vvomen were municipalities to attend sehool, and educa- tect themselves. Next, a representative from well aware ofthe threat that HIV infection tional levels were low. Most residents spoke the US foundation that funded the commu- held for them and their children. When asked Zulu; many also spoke some English. Among nity education research project spoke bnefly who was most at risk, they immediately this large population, still disenfranchised at in English, and then American researchers replied that it was women; they said that this that time, a v ibrant informal economy ex- mentioned the development ofthe female was beeause their partners had other women. isted. Bricks vvere made in the settlement and condom. and they themselves were dependent on men used to build houses. Although men still had At this meeting, the women were very for support. As before, they made the point more options for paid employment, women outspoken in front ofthe men. Women in that if they had jobs, they would be able to in the settlement, because of their proximity the audience stood up and argued with the refuse sex to men who refused to use con- to the Durban markets and sen ice oppt>r{uni- men in the back ofthe room who claimed doms. The point was also made, without ties, had more ways to support themselves that the young girls hanging around the har- prompting, that women should be able to than women in the rural village Because of bor were "asking tor tl [sex]"" The women avoid unprotected sex vv ith a number of men. these opportuniiies. women who migrated to talked about the lack of economic alterna- "Poverty makes prostitutes of us." they said. the new informal settlements on the periph- tives that led vvomen to sell sex. One woman The connection beuveen sex, particularly sex ery ofthe city were often single heads of explained (hat a woman who had spent the with more than one partner, and HI\' infec- households. They found work as household entire day in Durban unsuccessfully looking tion was made again and again. Also re- servants or babysitters to support their fami- for work and returned to the settlement with peated was the fact that condom use prevents lies. Many also tned to generate cash by mak- no money might exchange sex for 10 rand to infection. ing candles, baskets, and clothes and selling buy sugar for her children that night. The Although the women at the meeting them locally or in Durban. women did not see these situations as being demonstrated a knowledge of HIV risk and Although the informal settlements restricted to a group of "sex workers" or ofthe role of male condoms in protection, lacked elccincity. nearby townships were "prostitutes" bul rather talked about the sale when we asked if their partners vvere using sources of information and television. It is of sex as one last option available to women male condoms, no woman said yes. When important to noic that people in the area did whose families were in desperate need of we asked v\hy not. one woman commented, have access to international media During money and food. "It is good to have women's groups to help one informal discussion, a group of young The women were explicit about eeo- us. but ihere is no group to support you when people asked about nots that were ttccurnng nomic needs and said that the best method in New York City at lhe time we were talking you are alone with your husband," Another they could imagine for preventing HIV in the woman said. "It might be better if we had a

1044 American Journal of Public Health July2000, Vol. 90. No. 7 Public Health Matltrs fctnalc condom " and this comment led to an Namibia: The Ovamho-Speaking Region died of one ofthe opportunistic diseases, excited discussion. fJ996) such as diarrhea or tuberculosis. The women asked to see a female con- A pastor in the area told us that people dom, and when we returned a few da\s later, in I9Q6. Richard I,ee and I.S. visited the did not belie\e in .MDS because 'no one has we brought a demonstration kit vMth us. The Universitv of Namibia in Windhoek to work died oi It" He claimed YouH ne\er know if reaction was immediate and posili\c AUiui with Namibian students in sociocultural re- somebody died of AIDS, only maybe after 25 women had collected in ihe cnmmunity search on HIV. Two students, a man and a somebody is buned it is a rumor" He added hall to meet us. and aficr the dcninnstratum. woman from the Ovambo area, then accompa- that the chuah "can't ask what the sickness is. they eagerly handled the condoms and iok- nied us to their home region, serving as even for >our own child. They hjve ct'nies ingly practiced using (hem with the dildo pro- guides, informants, traaslator^. and b\ the end for sicknesses, one will ne\er find out what vided by the liaison pcrvm. When we cau- ofthe project. interMewers and researchers. the person died of . . It is a heterosexual mat- tioned that men might reject their use. as they In the Ovanibo-speaking region, we in- ter, and ihe church doesn't krww how or what did the male condom, the women overrode terviewed hospital administrators, nurws and to do ... It IS not discussed because there is our hesitation. 'We can use it and teach other doctors, church leaders and counselors, and not evidence that the person died of.MDS." people to use it. It is better that \ou bnng it men and women in their homesteads in the Like the doctors and nuf^cs. the pastor quickly and that it is free." communities along the road north. We visited claimed that people dtd not talk aK^ut .MDS This opened the way for a discussion the homestead of one student and he intro- openly or admit to others thai ihcy had the di.s- once again ofthe problems women faced in duced us to his mother, his aunt, his brothers ease. e\en when they might be dying from it. the area, the lack of adequate housing and and sisters, and neighbors in the farming The pastor also said that he was op- employment being paramount. One woman area. His father and older brothers were posed to the distribution of condoms, which said. "In these small 2-roomed shacks the away, working in a town abt)ut 2 days' dnve was based on the assumption that people did children can hear e\er\ihing .. . maybe it will distant. Most of tbe famihes in this area re- not practice chastity before and be difficult to talk ab

July 2000. Vol. 90. No. 7 Amcncan Journal of Public Health 1045 Public Health Manen

where water had to be fetched from a faucet miles down the highwa\. we found women out that we could not provide female coti- doms and that they were expensive, one a mile away, most ofthe food was prepared who were concerned and knowledgeable from subsistence crops, and the utensils in about the AIDS epidemic in their midst woman insisted hke the women in Durban. the enclosed patch of sand that served as a In the middle of a hot, dusty day we "Go to the ministry [of health] and tell them to order female condoms. Maybe it's bet- kitchen were fashioned from local materi- were broughi to the first inten iew b> our als—we found extensive knowledge about student, who bad gone to a religious school ter if we have this report [that we said we AIDS. Both women talked about people they with one ofthe daughters in this homestead. were writing] and wnte them a letter." had known who died of AIDS. A couple who Inside the compound of mud shacks and We then interviewed a man and hjs girl- lived across the highway had both died re- shanties made (if corrugated iron, we were fnend in the shanties along the edge ofthe cently: the wife had asked her neighbor to greeted hy a woman carrying a small boy road which housed the poorest laborers of visit her so that she could tell her neighbor and •Nurrounded b\ many other children We the region The man and the woman said they she had AIDS and that others should know. began talking lo (he woman, and she called knew people who had died of AIDS and they in her sisters, who then called in their teen- knew about the male condom, but they were The 2 women also told us about a member of aged daughters to join the discussion. Al- not willing to talk to us for long. their church who had been in the hospital though bolh of our students were with us. The next significant interview was with and had wntten a letter to be read during the which meant we were 2 men and 2 women, our student's mother and aunt. Since he Sunday service. He said he was dying of the women did not seem reluctant to discuss thought his mother would be more comfort- AIDS and he wanted people to know. He did contraception or .AIDS. able talking with women, he and Richard Lee not want to die in secret but wanted to warn other people about the disease. The women '•• Women in this compound were very went to interview a neighbor while the told us that everyone thought his girlfriend aware of the issue of AIDS and also knew woman student and IS stayed to talk with his people w Ith AIDS, To quote one of the mother and her sister. Both women were in and her baby must have AIDS and that she women. "People know that there is AIDS and had left the distnct and disappeared. They they talk about it They are not hiding it an> were also wondenng whether her next boy- more, because they know people are getting friend, who now had another girlfriend, it. They know people that have AIDS and "We want the female might be infected. they talk to them People m the cummunit\ condom today." As this example demonstrates, people are taking care of AIDS victims ' One ofthe were very aware ofthe possibility for hetero- sisters took up the discussion. She said they sexual and perinatal transmission of AIDS. were all concerned about AIDS "Women are Although this awareness sometimes led to very open. They talk to each other about stigmatization (which might explain why the AIDS. . . . Yes, they acknowledge that it is their 40s. They showed us around the home- girlfriend left the area), people knew very possible they ha\e it. The\ are \cr\ afraid." stead The small buildings were made of mud well the mode of transmission. Devout, re- These women knew that AIDS was sex- with straw roofs and were separated by bam- spectable churchwomen told us that women ually transmitted and they wanted their hus- boo screens. Each son and daughter over a had no say in an Ovambo bedroom—they bands to use condoms hut the\ could not in- certain age had his or her own hut. and the could not ask a man to use a condom or dis- sist. "It's different," said one "There are entire compound was surrounded by a bam- cuss any other sexual issue However, they some women who ask men to use eondoms boo wall. Outside the wall were dried-out were extremely enthusiastic about the female hut some women don't say it." Later another fields where cattle grazed The student's condom, saying that this was something said "A husband will not agree to use con- mother showed us the beer she had brewed women could use. It would be under their doms with his wife. ... He says he sleeps alcoholic for adults, nonalcoholic for chil- control. They said explicitly that if they used around hut will use condoms outside, but she dren, and the enclosed but rootless area a female condom they would not be inviting a can't be sure " They said they were worned w here she and her sister cot^kcd in huge iron beating, as they would if they dared to ask a thai they would get AIDS and die. pots over an open fire, using spoons and man to use a condom. E\entualK. we showed the women the other instruments made from local material. These cases give a sense ofthe dynam- Four little children, du.sty and dressed in rags, female condom They became vcrA animated ics between women and men in Ovambo so- played around our feet as we all siit down on and said it was what they needed: "We want ciety They suggest areas for mobilisation for the ground under the trees for the interv lews. the female conjom today " One woni;in the treatment and prevention of HIV infec- noted 'It IS important that the semen w ill re- However, lest this homcsteiid sound tion and demonstrate the significant agency, main in the woman because men don't like lo like an unchanged traditional setting, it open-mindedness. concern, and knowledge take the semen out." Another woman said should be noted thai the son who was work- to be tound among women who might at "You can bnng it [the condom] here." ing with us was a college siuilent (the first in first appear to be most constrained by church The women asked where female con- the family), the husband had a ci\il service and family. doms were a\ ailahle and discussed the cost of job far a\va\, and in the teenaged son's hut. the condoms at the IOCJI pharmacy. They next to his bed was a pack of condoms. The Namihia: Rundu. a Kavango-Speaking were eager to use female condoms; they said mother worked as a liaison for the church. Region {1997) that although they could not sa\ anything to helpinu to identify children with disabilities. their husbands, they could use anything the\ The student who was working with us had In July 19Q7. Richard Lee and I.S. re- chose. They said definitely that it did not run away as a teenager to join SWAPO in matter tlial the men could ^cc the female con- Angola when the South African army occu- turned to Namibia with Karen Brodkin to dom, if It w a,s ihcirs. the> had the nght to u.se pied Namibia, returning only alter Namibia conduct interviews among the Kavango peo- it: "A woman can make her own decision." had won its independence. ple, the second largest population in northern One woman said. "This will be prolecti\c Namibia. At Rundu. a regional center on the In this ••traditional" compound in a Irom the woman's side." W hen we pointed btirder between Namibia and .'\ngola, we met rural area in the far north of Namibia— with health workers, workers frotn non-

1046 American Journal of Public Health July 2000, VoL 90. No. 7 Public Health Mafters governmental organizations, and the head of protect themsehes. e\en if it meant chang- the home, and vvere the onlv group visited the health district (an extrcmcK .lrticulaie ing sexual mores. The women in the sewing that displaved the pa.ssi\e response and dis- and knowledgeable nurse rniined hy the com- cooperative were familiar with .MDS They empowered demeanor sometimes ascnbed to munity health movement in South Africa), had il> be nexr With ap- The situation was ver> difterent in the sewing awperativc. propriate resources and support, they said urban settlement on the outskirts of Durban. The sewing faetory. which employed they were ready to act. Although the\ had onlv recentk come from about 60 women, had been started at the sug- rural area>. the women here were articulate gestion of Oxfam Canada workers and was The Kalahari Desert (Namibia. 1996: and ptihticized. they shovsed no hesitation in now an active concern run b\ the women Bot.wvana. 1999): TheJu/hoansi speaking up in the presence ot men. contra- themselves. They worked on their sewing dicting the men when moved to do sti They machines at the back of a large shop. Their Next we visited the Ju "hoansi ofthe were open and explicit about their experi- products were displayed in ihe front ofthe Kalahari Desert, who were first contacted ences with men. equating their bargaining store, with no division between the seam- 30 years ago by Richard Lee At that time, power with their need tor monev and re- stresses and the customers. they were gatherers and hunters living m sources: "Poverty makes pr<.»Ntitutes of us." We walked into the store and started seminomadic biind societies, with egalitanan Jobs would buv them independence They talking to the women at their sewing - relations between men and women.'' ' The were familiar with the male ctmdom but were chines. Since it was an impromptu meeting, Ja hoansi now live in settled villages around unable to insist that men use it Phe female rising out ofour request to be introduced in- government-supplied water sources. They condom was just what they w:uited; it would formally to local women, we did not start by support their ht>useholds on a combination of give them the control thev sought How can talking about HIV/AIDS. We asked the government lood supplements, temporary we demand that the government give us the women about their sewing and the matenals gtnemment-sponsored work groups, gather- female condom, thev asked. they used. They asked us what we did. and ing, and infrequent hunting The women from Rundu. Namibia, we told them we were concemed w ith .MDS Here, we got a dirterent response. As at also sav\ the need for political action, they The women said they knew about HIV/ our other sites, men and women knew about wanted to mobilize and insist on their rights. AIDS. They had been told the modes of HIV AIDS. They knew people who had Namibian vvomen from both Rundu and the transmission by nongovernmental organiza- died ofthe disease However, the Ju 'hoansi Ovambo region, like the women in Durban, tion workers. They seemed somewhat bored women s description of their sexual negoti- did not believe that they could ask a man to by the topie. ations differed from those ofour other in- use a male condom Although thev were just At the end ofthe conversation I (I.S.} ca- formants. (Jne single woman, expressing as emphatic ab<^iut their wi^h to protect them- sually mentioned the female condom. One of the groups view, said "If he won't wear a selves from HIV .AIDS as the women m Dur- the women, who had been listening in a condom. I won't have sex with him " An- ban, the Namibian women expressed a simi- desultory way. tumed around and said. 'Oh! other woman, exhibiting the autonomy of lar sense of cultural limits in their approach I've seen one of those in the drugstore here," women described by Eleanor Burke Lea- to sexual negotiation, Another woman said. "Do you ha\e one. can cock. Richard Lee. and others." '"* said A complex cultural distinction underlay we see it?" 1 said I had not brought one with "He can't control me. I wili do what I want, the demands oi the women from Durban and me, but I asked "Would you use it''" The and if he doesn't do what I want. I don't Namibia. In their system of thought, women women said "Yes. yes. tell us about it," I have to have sex " have rights over their own bodies, as men started to talk about the female condom as The young Ju 'hoansi men also talked have over theirs. It is a man's prerogative to one method that women could use, and sev- of their relations with Ju "hoansi women as use or not use a male condom. However, al- eral women left their sewing machines and negotiations with equal agents whose opin- though women cannot control men's actions moved closer to listen. ions had to be taken into account. In fact, in manv situations outMde the home, within We drove back to our rooms for the the young men said they hoped that a girl the bedri.H>ni a ni;in cannot prevent a woman demonstration materials. When we retumed who became a sexual panner would agree to from making decisions that aflect her own about an hour later, the women were waiting be the man's wife. boUv. Hence, when told aU.>ut the female con- for us. They left their sewing machines, dom, the women became extremely enthusi- looked at the books and pictures we had astic. They could and vMiuld use this device, brought, handed the female cttndom around, Discussion becau.se it would be within tlieir accepted do- and asked us to give them some. They said main of autt.momy. they were too expensi\e for them to buy. 1 The 5 sites we visited offer contrasting Thi> point was confirmed indepen- said they would have to get their ow n govem- opportunities through which women might dentlv by an ANC man who visited one of ment to provide them, and that this would be be helped to protect themselves against HIV our meetings in WMS at the informal settle- possible only if they mobihzed collecti\ely. infection; no methinJs are currently in use or ment tn Durban He said explicitiv with ref- as they had for the sew mg cooperative, to playing ellective roles. At the first site, a rural erence to the female condom. "If it's in her make this a govemment pnonty. village in what is now Natal/K,vvazulu, South room and it is her condom, she can use it." These women wanted the condoms and Africa, women were, in W42. reluctant to Well .iware of .MDS. the women wanted des- were positive they could use them. They lllscus^ HI\' infection or contraception and perately to be helped to acquire this single wanted to make a political demand for tended to remain silent in the presence of possibility for protection. They knew that women's condoms—a reaction almost iden- men. They were pt>orly infomied abt>ut sexu- they could not control what their men did— tical to that of the women in the Durban in- ally transmitted diseases in general and about seeking other partncrN when thev were away formal settlement and the women in the HIV in particular. They had a small role in from home, for instance. Men might use the Ovambo region. Once again it became clear community organizations, appeared to be male coiuiom on such occasions, but not that given the resources, people would act to subservient to men outside as well as within with their wives.

July 2000. Vol, 90, No. 7 Amencan Joumal of Public Health 1047 Public Health Mattcn

search Program and was canied out by Rjchard Lee. It is striking that both the women tn the lective organization. They did not expect that Pombili Ipinge. Karen Nishua, Maria Nadjua, Karen urban setting m Durban and those in the rural wx^men's needs would be recognized or un- Brodkjn, and Ida Susser. sites of northern Namibia knew about AIDS derstood b>' the gov emment. but felt quite unable to preserve a monoga- mous relationship or to insist that their men References use condoms Yet both groups of women Conclusions 1, AlDSEptJemic Updates. Geneva. Switzerland: were quite confident that they could and Joint Uniied Nations Programme on HIV would use the female condom, and they Contrary to the view of African women AIDS and the World Health Organization; De- urged us to help them obtain some. as helpless victims, most ofthe women we cember 1949 Quite different were the Ju'hoansi spoke to saw themselves as active participants 2. Abdool Kanm 0. Presion-Whyte E. Zuma N. women, who assured us that they would in the search tor a \^-dv to pmtect themselves in Prevention uf HIV Infection for Women hy stand no nonsense from their men. Either the sexual situations. Nevertheless, their methods Women in \atal. South Africa Durban. South Africa Research Institute for Diseases m a men would follow instructions to use con- of sexual negotiation are shaped by cultural and histoncal perceptions ofthe bounds ofthe Tropical Environment; 1993. Preliminary find- doms or the women would withhold sex The lnes. International Center for Research on human bodv Among some groups, the Ju young Ju/hoansi men confirmed this view Women: Women and .AIDS Program. of relations between Ju 'hoansi men and 'hoansi for instance, a woman can insist that a 3 Slein Z HIV pre\eniion: the need for methods women as negotiations between equals. We man use a male condom, and she can withhold women can use .4m J Puhlie Heallh. 1990; 80: must add that although AIDS ha,s certainly hit sex if he refuses .Among other groups, a Ju/ 'hoansi villages, we have little evidence woman's request that her partner use a male 4. Schoepf B. Women at risk: case studies from that the male condom was actually used. In eondom is seen as a challenge to his authority. Zaire In Herdt G. Lindenbaum S.eds TheTime addition, many ofthe sexual partners of A woman controls her own body, however, of AIDS SiKial Anulysi.s. Theory ami Method. and has the nght to use a female condom. In Newbury Park, Calif: Sage Publications; 1992: young Ju 'hoansi women today are not 259-286. Ja^'hoansi men but men from neighbonng our interviews in these \Bnous settings, both urt)an and rural, the women demanded that the 5. Farmer P. Lindenbaum S. Good M. Women, populations who are working in the Ju poveru and AIDS: an introduction. Cult MeJ 'hoansi region. Ju^'hoansi women may not female condom be provided to them. PsyLhiarn I9'i3.l7 387 397 have the same autonomy in their relations Woman-controlled methods of protec- 6 Gupta G. Weiss E Women's lives and sex- im- with sueh partners, who have greater access tion, such a-s the female condom, are regarded plications for AIDS pre\ention Cult Med Psy-- to work and money than the Ju 'hoansi as culturally appropriate among many men chiatry- I993;I7:399-112 women or the Ja "hoansi men and women m Southem Africa and are crucial 7. Reid E Placing women at the center ofthe to the future of Hl\' AIDS prevention. Since analysis In: Bond G. Kreniske J. Susser I, Vin- At least 3 generalizations can he made cent J, eds .AIDS in .Africa ami the Canhhean. from these studies. First, with the exception women have been clearly asking for such Boulder. Colo: WestMew Press; 1997,159-165. of those in the South Afncan rural village, methods, political and economic concerns, 8. Parker R. Barbosa R. Aggleton P. eds Framing our respondents were hy no means passive or combined with historically powertul pattems the Se.Miai Subject Berkeley: Unnersity of Cal- submissive, and they were well aware oftheir of gender discrimination and neglect of ifornia Press; 2(KX): 110-115. vulnerability to HIV infection. Second al- women's sexuality, must be considered the 9. .Abdool Kanm Q. .Abdool Kanm SS. South Af- though they are well aware ofthe hazards of main harriers to the development and distrib- nca: host lo a new and emerging HIV epidemic. unprotected sex. women in southern Africa ution of methods women can control. D Sex Transm Infect. I999;75:139-147. do not have access to methods they believe 10 Bond G. Kreniske J. Susser I. Vincent J. eds. AIDS tn .Africa and the Canhhean Boulder. they could use. Faces brightened at our Colo: Wcst\ieu Press; 1997 demonstration ofthe female condom, and the Acknowledgments 11 Leacock E. Lee R. eds Ptililies and History in women responded eagerly to the suggestion Research ai 2 sites m South .Africa in 1 Wl and \'^92 BanJ Societies Cambridge. England: Cam- that these condoms might be made available was tiinded by the International C enter for Research bndge LIniveniity Press. 1982 to them. Unlike some women in the devel- on Women jnd was tamed out by Quarraisha Ab- 12, Lee R The 'Kim^ San. Men. iVomen and ttbrk oped world but similar to women studied in dool Kanm. Nkosasana Zuma. Eleanor Prcslon- in a Foraf^ing Society Cambridge. England: Mexico. Senegal, and Costa Rica, they saw Wh\ic. Zcna Slcin. and Ida Susser The researchers Cambndge Uiu\ersit\ Press. 1979 the female condom as a serious option." wish lo thiink the PSC-tL'N>' Fellowship from the 13 Lee R The Dohc Ju hoansi. New York. NY; Third the women understtxxl that in order lo City Dniversily ol" \e« ^brK and Ihe i;ni\ersity ^ii Harcoun Brace. 1993. Natal for suppon and asi,islance m i^^5> Research obtain this protective device, they would I 4 Shostak M. Nisa: The Life and Hbrds of a in Namibia in 1W6, 1W7. and WW was funded by IKung iVoman. Cambridge. Mass: Harvard Uni- have to take political action, probably by col- the Fogariy AIDS Iniernational Training and Re- versity Press. 19X1.

1048 American Journal of Publtc Health July 2000, VoL 90, No. 7