South African poor, black women are the face of health inequity

We are critically cognisant that South Africa is recognised as having one of the highest rates of inequality in the world. We recognise that tackling deep inequalities requires an express recognition of the intersections of class, race, gender, disability, sexual orientation, gender identity and expression and nationality.  And in embodying a feminist ethos we must ask a number of critical questions.  Today we are asking, how we can strengthen the capacity of leaders for social change and reimagine health, inequality and social systems, without considering gender-based violence (GBV)?  How do we understand and tackle inequality when not challenging the gendered power inequities that give rise to GBV?

According to the Africa Health Organisation (AHO), South Africa has one of the highest rates of violence inflicted on women and girls in the world. A 2014 report by KPMG takes this statistic further in pointing out that GBV and violence against women in particular “is one of the most expensive public health problems globally and has a fundamental impact on economic growth, which can span several generations”.  Poor black women are the face of this health inequity.

While many a study has been concluded and far more news articles written, there is currently no comprehensive study on the impact and costs of GBV.  It is widely accepted that these studies can never represent a holistic picture for two primary reasons — the highly conservative nature of research methodologies, and, perhaps more significantly, the chronic and complex levels of underreporting.  However, even with poor methodologies and excessive levels of underreporting, the statistics remain grim.  And it goes without saying that GBV contributes significantly to the disease burden in our country.

Covid-19 adds to this pot. Like with other socioeconomic inequities, Covid-19 amplified the impact and resultant responsibilities on women, particularly those in precarious jobs, single parent households, frontline workers, the myriads engaged in the double burden of unpaid care work and those in abusive relationships. While there were questionable reports that there was a reduction in GBV during the national lockdown, 2 300 GBV cases were reported in the first week of lockdown alone. A July 2020 survey by the Foundation for Human Rights indicated that their community advice offices reported a 54% increase in GBV cases during lockdown across all provinces. But, as with other similar studies, they too cautioned about underreporting; this time, they attributed underreporting to restrictions on movement created by the lockdown.

The cases of GBV escalated following the opening of alcohol outlets at the end of the level 5 lockdown. Add to this the exacerbated chronic psychological distress women experience not only under lockdown, but as survivors of GBV and as our own research revealed, the less widely-reported violence women experience by simply being black women at the bottom of South Africa’s socioeconomic hierarchy, and therefore being “particularly vulnerable to job losses, lost income and an inability to access UIF funds”.

GBV is real

• 51% of women in SA say they’ve experienced GBV, with 76% of men saying they’ve perpetrated GBV at one stage in their lives (2010 Gauteng sample).  A similar study revealed that one in five women report that they have experienced violence at the hands of a partner.

• In 2019/20, 53 293 sexual offences were reported, an average of 146 per day, up from 52 420 in 2018/19. Most of these were cases of rape. Of this the police recorded 42 289 rapes in 2019/20, up from 41 583 in 2018/19, an average of 116 rapes each day (SAPS Crime Stats).

• In 2019/20, a total of 2 695 women were murdered in South Africa. This means a woman is murdered every three hours.

• Femicide is five times higher in South Africa than the global average, with South Africa having the fourth-highest female interpersonal violence death rate out of the 183 countries listed by the WHO in 2016.

• At the start of level 3 lockdown, 21 women and children were murdered in two weeks, leading the president to cite “…two devastating epidemics: Covid-19 and GBV”.

The earlier cited KPMG report, using a conservative estimate of a GBV prevalence rate of just 20% — and by its own account a partial estimate of the true costs — still manages to estimate that GBV costs South Africa between R28.4-billion and R42.4-billion per year, which amounts to 0.9% to 1.3% of our GDP annually.  To give this some context, this is equivalent to employing an additional 200 000 primary school teachers for a year, or providing National Health Insurance to a quarter of the South African population.

The statistics and figures exclude the vast amount of incidents that go unreported, as well as the incident of violence that are not “overt” or those considered “violent”, and the normalised and pervasive gendered violence and discrimination experienced daily, particularly by women and members of the LGBTI+ community, not to mention the privileges and impunity enjoyed by perpetrators and the fear that their actions set off.

GBV perpetuates and reinforces gender inequality, impeding the contributions women and girls can make to social change and health equity.  No leadership development fellowship on health equity in South Africa will be complete without studying the global and local literature, normalisation and pervasiveness of GBV and in doing so centering questions of power, privilege and positionality.

This is particularly important, as:

• Violence in women’s lives ranks higher than smoking, obesity or high blood pressure as a contributor to death, disability and illness;

• There are significant links between GBV and a range of other sexual and reproductive health problems, including sexually transmitted disease, forced and unwanted pregnancy, unsafe abortions, traumatic fistula, maternal morbidity and mortality, adverse pregnancy outcomes and even death;

• There is a significant association between perceived or actual HIV-risk and higher levels of GBV. UNAIDS points out that women who have been physically or sexually abused are 50% more likely to acquire HIV in some regions of the world;

• The WHO indicates that women who have been physically or sexually abused are 16% more likely to have a low-birth-weight baby, and they are twice as likely to have an abortion;

• Evidence from India has established a link between GBV and chronic malnutrition;

• Female victims of violence exhibit risk-taking behavior, such as unhealthy feeding habits, substance abuse, alcoholism and suicidal tendencies; and

• Female victims of violence experience psychological distress and challenges with mental health.

Reimagining the dynamics of health inequity and engaging community actions for improving health equity necessitates building community, equality and care.  This must not only be an ideal, but will be mirrored in the fellowship.  Fellows with successful social change initiatives will look at how GBV prevents women from leading healthy and productive lives.  We welcome fellows who are able to harness catalytic communities against GBV and we commit to ensuring that GBV forms a critical component of the fellowship curriculum. Not doing so would be doing a grave injustice to advancing health equity in South Africa.