Who Is Centered in the Humanitarian Response to Gender-Based Violence? A Critical Discourse Analysis of the Survivor-Centered Approach.

Since the 1990s, the international humanitarian system has developed approaches, tools, and standards for addressing gender-based violence (GBV) in emergencies premised on the survivor-centered approach (SCA). Utilizing critical discourse analysis, we explore how articulation of SCA within humanitarian discourse aligns with its stated intent to return control to survivors. The analysis reveals that humanitarian system power dynamics distort the application of SCA, leaving humanitarian service providers in charge of assessing the best course of action or severely limiting survivors' choices. We propose a survivor led approach as more aligned with the feminist and transformative goals of humanitarian action against GBV.

Understudied and underaddressed: Femicide, an extreme form of violence against women and girls.

Little is known about the prevalence and dynamics of femicide, a persistent form of violence against women and girls, due to challenges associated with its documentation. Research by Abrahams and colleagues comparing rates of femicide in South Africa over 18 years, however, suggests that femicide is preventable.

Gender-based violence against adolescent girls in humanitarian settings: a review of the evidence.

Adolescent girls face elevated risks of gender-based violence in humanitarian settings because of the intersectionality of age and gender, and the additional and exacerbated risk factors relevant to emergencies. Because there is no clear division of labour between the gender-based violence and child protection sectors, adolescent girls are often neglected by both groups, and violence against this subpopulation goes unaddressed. This Review presents an adapted ecological framework for gender-based violence risks facing adolescent girls in emergencies, synthesises the scant evidence for gender-based violence prevention and response, and identifies barriers to effective and ethical measurement and evaluation of programme effectiveness. Although nascent evidence highlights promising interventions for transforming girls' attitudes about violence and gender inequity and improving psychosocial and mental wellbeing, little evidence supports the ability of existing approaches to reduce gender-based violence incidence. A more explicit focus on adolescent girls is needed when designing and evaluating interventions to ensure global efforts to end gender-based violence are inclusive of this population. TRANSLATIONS: For the Arabic, French and Spanish translations of the abstract see Supplementary Materials section.

Discriminatory attitudes and practices by health workers toward patients with HIV/AIDS in Nigeria.

BACKGROUND: Nigeria has an estimated 3.6 million people with HIV/AIDS and is home to one out of every 11 people with HIV/AIDS worldwide. This study is the first population-based assessment of discrimination against people living with HIV/AIDS in the health sector of a country. The purpose of this study was to characterize the nature and extent of discriminatory practices and attitudes in the health sector and indicate possible contributing factors and intervention strategies. The study involved a cross-sectional survey of 1,021 Nigerian health-care professionals (including 324 physicians, 541 nurses, and 133 midwives identified by profession) in 111 health-care facilities in four Nigerian states. METHODS AND FINDINGS: Fifty-four percent of the health-care professionals (550/1,021) were sampled from public tertiary care facilities. Nine percent of professionals reported refusing to care for an HIV/AIDS patient, and 9% indicated that they had refused an HIV/AIDS patient admission to a hospital. Fifty-nine percent agreed that people with HIV/AIDS should be on a separate ward, and 40% believed a person's HIV status could be determined by his or her appearance. Ninety-one percent agreed that staff and health-care professionals should be informed when a patient is HIV-positive so they can protect themselves. Forty percent believed that health-care professionals with HIV/AIDS should not be allowed to work in any area of health-care that requires patient contact. Twenty percent agreed that many with HIV/AIDS behaved immorally and deserve the disease. Basic materials needed for treatment and prevention of HIV were not adequately available. Twelve percent agreed that treatment of opportunistic infections in HIV/AIDS patients wastes resources, and 8% indicated that treating someone with HIV/AIDS is a waste of precious resources. Providers who reported working in facilities that did not always practice universal precautions were more likely to favor restrictive policies toward people with HIV/AIDS. Providers who reported less adequate training in HIV treatment and ethics were also more likely to report negative attitudes toward patients with HIV/AIDS. There was no consistent pattern of differences in negative attitudes and practices across the different health specialties surveyed. CONCLUSION: While most health-care professionals surveyed reported being in compliance with their ethical obligations despite the lack of resources, discriminatory behavior and attitudes toward patients with HIV/AIDS exist among a significant proportion of health-care professionals in the surveyed states. Inadequate education about HIV/AIDS and a lack of protective and treatment materials appear to contribute to these practices and attitudes.

Physician participation in human rights abuses in southern Iraq.

CONTEXT: Physicians are known to have participated in human rights abuses in Iraq during Saddam Hussein's Baathist regime, but the nature and extent of that participation are not well documented. OBJECTIVES: To characterize the nature of physician participation in human rights abuses, identify structural factors that facilitated physician participation, and assess approaches for accountability and for prevention of future physician participation in abuses. DESIGN, SETTING, AND PARTICIPANTS: A self-administered survey in June and July, 2003, of a convenience sample of 98 physicians and semistructured interviews of hospital directors and physicians in 3 major hospitals with general surgical units in 2 cities in southern Iraq. MAIN OUTCOME MEASURE: Respondent reports of peer and self-participation in human rights abuses in Iraq since 1988. RESULTS: The majority of participants were male (88% [86/98]) and Shi'a Muslims (97% [95/98]). Respondents reported a mean of 6.8 years in practice. A total of 71% of respondents (65/91) reported that torture was a problem to an extreme extent in Iraq since 1988. The proportion of respondents indicating that, since 1988, their physician peers as a group were extremely or quite a bit involved in human rights abuses included 50% (42/83) for nontherapeutic amputation of ears as a form of punishment, 49% (39/79) for falsification of medical-legal reports of torture, and 32% (25/78) for falsification of death certificates. Fewer numbers of respondents (range, n = 2 to 6) reported participation in abuses themselves. More than half (52% [48/92]) indicated that physicians did not willingly participate in these abuses; 93% (52/71) reported that the Iraqi paramilitary force Fedayeen Saddam was responsible for initiating physician complicity. Fear of harm to oneself or family members was a common explanation for complicity. Respondents reported that physicians who refused to participate in abuses faced consequences including loss of job, imprisonment, torture, and disappearance. Respondents reported on preventive measures that should be undertaken to prevent physician involvement in future abuses, including increasing human rights and ethics education of physicians (99% [79/80]), legal provisions to ensure effective monitoring (97% [73/75]), punitive sanctions for physicians who commit abuses (96% [77/80]), and ensuring the independence of physicians from state authorities (95% [76/80]). CONCLUSIONS: Although not generalizable beyond the study participants, the findings of this study suggest that among those surveyed, physician participation in human rights abuses included falsification of medical-legal reports of alleged torture, physical mutilation as a form of punishment, and falsification of death certificates. As Iraq rebuilds, it is essential that the country address these violations and enact measures to prevent physicians from future complicity in human rights abuses.

Human rights abuses and concerns about women's health and human rights in southern Iraq.

CONTEXT: Although human rights abuses have been reported in Iraq, the full scope of these abuses has not been well documented. OBJECTIVE: To assess the prevalence of human rights abuses since 1991 in southern Iraq, along with attitudes about women's health and human rights and women's rights and roles in society, to inform reconstruction and humanitarian assistance efforts in Iraq. DESIGN: Cross-sectional, randomized survey of Iraqi men and women conducted in July 2003 using structured questionnaires. SETTING: Three major cities in 3 of the 9 governorates in southern Iraq. PARTICIPANTS: A total of 1991 respondents representing 16 520 household members. MAIN OUTCOME MEASURES: Respondent demographics, information on human rights abuses that occurred among household members since 1991, women's health and human rights, opinions regarding women's rights and roles in society, and conditions for community health and development. RESULTS: Respondents were a mean age of 38 years and were mostly of Arab ethnicity (99.7% [1976/1982]) and Muslim Shi'a (96.7% [1906/1971]). Overall, 47% of those interviewed reported 1 or more of the following abuses among themselves and household members since 1991: torture, killings, disappearance, forced conscription, beating, gunshot wounds, kidnappings, being held hostage, and ear amputation, among others. Seventy percent of abuses (408/586) were reputed to have occurred in homes. Baath party regime-affiliated groups were identified most often (95% [449/475]) as the perpetrators of the abuses; 53% of the abuses occurred between 1991 and 1993, following the Shi'a uprising, and another 30% between 2000 and the first 6 months of 2003. While the majority of men and women expressed support for women's equal opportunities for education, freedom of expression, access to health care, equality in deciding marriage and the number and spacing of children, and participation in community development decisions, there was less support among both men and women for women's freedom of movement, association with people of their choosing, and rights to refuse sex. Half of women and men (54% and 50%, respectively) reported agreeing that a man has the right to beat his wife if she disobeys. Fifty-three percent of respondents reported that there were reasons to restrict educational opportunities for women at the present time and 50% reported that there were reasons to restrict work opportunities for women at the present time. CONCLUSIONS: Nearly half of participating households in 3 southern cities in Iraq reported human rights abuses among household members between 1991 and 2003. The households surveyed supported a government that will protect and promote human rights, including the rights of women. However, currently, neither men nor women appear to support a full range of women's human rights.

Child labor. A matter of health and human rights.

Despite the existence of laws in India that prohibit the labor of children under age 14, 70 to 115 million children between the ages of 5 and 14 are estimated to be part of India's labor force. Child labor in the agriculture sector accounts for 80% of child laborers in India and 70% of working children globally. From May 2001 to July 2001, Physicians for Human Rights (PHR) investigated the health experiences of 100 children in hybrid cottonseed production in rural Andhra Pradesh. Eighty-eight percent of the survey participants were girls, ages 7 to 14. PHR found that children worked on average 12 hours a day, were frequently exposed to pesticides, and were not provided with safety equipment, not even shoes or water to wash their hands and clothes. Children reported having frequent headaches and dizziness and skin and eye irritations after pesticide spraying. All 100 children reported that they were unable to go to school during the hybrid cottonseed season due to work demands. Ninety-four children reported to PHR that they would rather be in school. In addition, a majority of child workers interviewed by PHR reported physical and/or verbal abuse by their employers. Moreover, PHR interviews with representatives of multinational and national companies revealed knowledge of child labor practices for up to 10 years. Child labor is a significant health and human rights problem for children in India. The progressive elimination of child labor practices will require the support of a wide cross-section of civil society.

Maternal mortality in Herat Province, Afghanistan, in 2002: an indicator of women's human rights.

CONTEXT: Maternal mortality rates in Afghanistan are estimated to be high. OBJECTIVE: To assess maternal mortality and human rights issues in Herat, Afghanistan. DESIGN AND SETTING: Cross-sectional survey of 4886 Afghan women living in 7 districts in Afghanistan's Herat Province, which included 34 urban and rural villages/towns. Using structured interviews/questionnaires, these women also provided maternal mortality information on 14 085 sisters in March 2002. A survey of health facilities in the 7 districts was also conducted. PARTICIPANTS: Mean (SE) age of the respondents was 31 (0.23) years (range, 15-49 years). The majority had received 0.35 (0.11) years of formal education and 4233 (88%) were married (mean [SE] age at marriage, 15 [0.3] years; range, 5-39 years). The mean (SE) number of pregnancies was 5.0 (0.08) and live births was 4.6 (0.2). RESULTS: There were 276 maternal deaths among 14 085 sisters of the survey respondents (593 maternal deaths/100 000 live births per year; 95% confidence interval [CI], 557-630). Of the 276 deaths, 254 (92%) were reported from rural areas. The respondents reported the following primary problems: lack of food (41%), shelter (18%), and clean water (14%). Of 4721 respondents, 4008 (85%) wanted to get married at the time of their wedding, but 957 (20%) felt family pressure. Of 4703 women, 4117 (87%) had to obtain permission from their husband or male relative to seek health care; only 1% (54/3946) reported not being permitted to obtain prenatal care. Of 4881 women, 597 (12%) used birth control, but 23% (1013/4294) wanted to use birth control. Of 4306 women, 3189 (74%) reported that decisions about the number and spacing of children were made by husband and wife equally. Of 4637 respondents, 519 (11%) reported receiving prenatal care. Of 4624 women, 40 (0.9%) reported a trained health care worker was present at birth; 97% (4475/4612) had untrained traditional birth attendants. Only 17 of 27 listed health facilities were functional and only 5 provided essential obstetric care. Only 35 physicians served a population of 793 214. CONCLUSIONS: Women in most of Herat Province, Afghanistan, have a high risk of maternal mortality. Human rights factors may contribute to preventable maternal deaths in the region.

Prevalence of war-related sexual violence and other human rights abuses among internally displaced persons in Sierra Leone.

CONTEXT: Sierra Leone's decade-long conflict has cost tens of thousands of lives and all parties to the conflict have committed abuses. OBJECTIVE: To assess the prevalence and impact of war-related sexual violence and other human rights abuses among internally displaced persons (IDPs) in Sierra Leone. DESIGN AND SETTING: A cross-sectional, randomized survey, using structured interviews and questionnaires, of internally displaced Sierra Leone women who were living in 3 IDP camps and 1 town, which were conducted over a 4-week period in 2001. PARTICIPANTS: A total of 991 women provided information on 9166 household members. The mean (SE) age of the respondents was 34 (0.48) years (range, 14-80 years). The majority of the women sampled were poorly educated (mean [SE], 1.9 [0.11] years of formal education); 814 were Muslim (82%), and 622 were married (63%). MAIN OUTCOME MEASURES: Accounts of war-related sexual assault and other human rights abuses. RESULTS: Overall, 13% (1157) of household members reported incidents of war-related human rights abuses in the last 10 years, including abductions, beatings, killings, sexual assaults and other abuses. Ninety-four (9%) of 991 respondents and 396 (8%) of 5001 female household members reported war-related sexual assaults. The lifetime prevalence of non-war-related sexual assault committed by family members, friends, or civilians among these respondents was also 9%, which increased to 17% with the addition of war-related sexual assaults (excluding 1% of participants who reported both war-related and non-war-related sexual assault). Eighty-seven percent of women believed that there should be legal protection for women's human rights. More than 60% of respondents believed a man has a right to beat his wife if she disobeys, and that it is a wife's duty/obligation to have sex with her husband even if she does not want to. CONCLUSIONS: Sexual violence committed by combatants in Sierra Leone was widespread and was perpetrated in the context of a high level of human rights abuses against the civilian population.