Differential returns from globalization to women smallholder coffee and food producers in rural Uganda.

BACKGROUND: Globalization-related measures to liberalize trade and stimulate export production were applied in Uganda in the late 1980s, including in the coffee production sector, to revitalize agricultural production, increase incomes to farmers and improve rural food security. OBJECTIVE: To explore the different effects of such measures on the health and dietary outcomes of female coffee and food small holder farmers in Uganda. METHODS: We gathered evidence through a cross-sectional comparative interview survey of 190 female coffee producers and 191 female food producers in Ntungamo district. The study mostly employed quantitative methods of data collection, targeting the sampled households. We also utilized qualitative data; collected three months after the household survey data had been collected and their analysis had been accomplished. Using qualitative interviews based on an unstructured interview guide, extra qualitative information was collected from key informants at national, district and community levels. This was among other underlying principles to avoid relying on snapshot information earlier collected at household level in order to draw valid and compelling conclusions from the study. We used indicators of production, income, access to food and dietary patterns, women's health and health care. Of the two groups selected from the same area, female coffee producers represented a higher level of integration into liberalised export markets. RESULTS: Document review suggests that, although Uganda's economy grew in the period, the household economic and social gains after the liberalization measures may have been less than expected. In the survey carried out, both food and coffee producers were similarly poor, involved in small-scale production, and of a similar age and education level. Coffee producers had greater land and livestock ownership, greater access to inputs and higher levels of income and used a wider variety of markets than food producers, but they had to work longer hours to obtain these economic returns, and spent more cash on health care and food from commercial sources. Their health outcomes were similar to those of the food producers, but with poorer dietary outcomes and greater food stress. CONCLUSIONS: The small-scale women farmers who are producing food cannot rely on the economic infrastructure to give them support for meaningful levels of production. However, despite having higher incomes than their food producing counterparts, the evidence showed that women who are producing coffee in Uganda as an export commodity cannot rely on the income from their crops to guarantee their health and nutritional wellbeing, and that the income advantage gained in coffee-producing households has not translated into consistently better health or food security outcomes. Both groups have limited levels of autonomy and control to address these problems.

Exploring equity and inclusion in the responses to AIDS.

The HIV and AIDS epidemic feeds on, and worsens, unacceptable situations of poverty, gender inequity, social insecurity, limited access to healthcare and education, war, debt and macroeconomic and social instability. The number of people living with HIV and AIDS continues to increase in several regions, most markedly in sub-Saharan Africa, the Pacific, Eastern Europe and Central Asia. The persistent nature of the epidemic and its increasing incidence in less powerful, more economically marginalised communities signals a need for a critical review of past policy and practice, particularly where this has left unchanged or worsened the risk environments that lead to new infection. Available evidence suggests that the caring and consumption burdens of AIDS have largely been met by households, limiting the capacities for future caring and mitigation of impact. Social cohesion or the collective networking, action, trust and solidarity of society, plays a positive role in reducing risk and dealing with vulnerability but is itself negatively affected by AIDS. This paper introduces the programme of work reported in this supplement of AIDS Care with an analysis of background evidence of community responses to HIV and AIDS. It explores how interventions from state institutions and non-governmental organizations (NGOs) support and interact with these household, family and community responses. How far is risk prevention reliant on individuals' limited resources and power to act, while risk environments are left unchanged? How far are the impacts of AIDS borne by households and extended families, with weak solidarity support? Where are the examples of wider social responses that challenge the conditions that influence risk and that support household recovery? Through review of literature, this background paper sets out the questions that the studies reported in this supplement have, in various settings, sought to explore more deeply.

Learning from diverse contexts: equity and inclusion in the responses to AIDS.

This paper situates the findings of the diverse studies reported in this journal supplement in a global context that both fuels the epidemic through inequality and poverty and also provides new opportunities for global commitments, solidarity and resources. The studies in this issue signal that, while information and awareness about HIV and AIDS is now high, there is still poor access to services for people to know their own risk and a deeper need to address the asymmetries of power and access to resources that influence the control people have over their sexual relationships and lives. The studies in this supplement describe, in very different contexts, responses to the impact of AIDS that are grounded within the actions of individuals, households and extended families, against a background of existing disadvantage in assets, endowment and access to state and private sector resources. Community networks reduce social isolation and provide solidarity to households struggling to respond to AIDS. The extra work involved is often done by women, particularly where the weakening of the state has left communities disadvantaged. The paper argues that connections across communities to support survival need vertical links to national and global resources, services and markets to support, sustain and transform lives. The studies demonstrate the positive effect of this through primary healthcare systems, non-government organisation support and the social movements of people living with HIV and AIDS. If the first wave of the global response to AIDS built awareness and an emergency response to prevention, treatment and care, there is now need for a 'second wave' that provides strong measures to connect communities to social, national and global resources. Elements of this 'second wave' include people's--especially women and young people's--access to services to know their individual risk, measures that enhance their autonomy and the need for a massive increase in investment in and access to decent work.

EQUINET: networking for equity in health in eastern and southern Africa

This short report outlines the perspectives and motivations for the work of the Regional Network for Equity in Health in eastern and southern Africa (EQUINET). It presents key areas of work on health equity being implemented to strengthen the state and public sector in health; organised around the active participation and involvement of communities. This includes work on strengthening people's power for health, on increased fair financing; and on retaining health workers and challenging trade policies that encroach on health. Such work faces challenges that can be met through increased regional networking to exchange experience, information and expertise, particularly given the demand for ìlearning by doingî. (AU)

Globalization and occupational health: a perspective from southern Africa.

Increased world trade has generally benefited industrialized or strong economies and marginalized those that are weak. This paper examines the impact of globalization on employment trends and occupational health, drawing on examples from southern Africa. While the share of world trade to the world's poorest countries has decreased, workers in these countries increasingly find themselves in insecure, poor-quality jobs, sometimes involving technologies which are obsolete or banned in industrialized countries. The occupational illness which results is generally less visible and not adequately recognized as a problem in low-income countries. Those outside the workplace can also be affected through, for example, work-related environmental pollution and poor living conditions. In order to reduce the adverse effects of global trade reforms on occupational health, stronger social protection measures must be built into production and trade activities, including improved recognition, prevention, and management of work-related ill-health. Furthermore, the success of production and trade systems should be judged on how well they satisfy both economic growth and population health.

Assessment of the health impact of occupational risk in Africa: current situation and methodological issues.

This paper presents information from the current monitoring systems in Africa, mainly Southern Africa, for occupational illness and injury and discusses the quality of the reported data in estimating the health impact of occupational risk. The paper presents and discusses the current profile of reported injury and fatalities for those countries for which data are available, in particular for the countries of the Southern African Development Community. These data indicate that the reported annual injury rates for wage workers in the Southern African Development Community region range widely from 0.35 to 49.42 injuries per 1,000 workers, and reported occupational fatality in the region ranges from 0.85 to 21.6 fatalities per 100,000 workers. Despite wide variability in reported rates (probably caused by variability in coverage and accuracy of reporting systems), transport, agriculture, mining and, to a lesser extent, construction consistently make up about three-quarters of all fatalities, with vehicle- or transport-related causes accounting for high proportions of fatal accidents. The paper identifies and discusses major sources and direction of bias and error in the reported data and suggests approaches for a better assessment of the health impact of occupational illness, injury, and mortality in African countries.

Collaboration between developing and developed countries and between developing countries in occupational health research and surveillance.

Collaborative occupational health and safety studies between counterparts in developing and developed countries and between developing countries have demonstrated their potential for improving occupational health and safety. Such collaboration in occupational health and safety is encouraged in the development of infrastructure in research empowerment and capacity building. This action includes the setting of priorities, the identification and documentation of problems, sponsorship, data bases and surveillance systems, technical support, methodology, publishing, research and training programs, controlled intervention, information exchange, and networking. Examples of priorities in occupational health and safety in the developing world include the informal sector (informally hired and independent workers), temporary work, pesticides, accidents, dusts, carcinogens, solvents, ergonomics, women and child labor, human immunodeficiency virus/acquired immunodeficiencey syndrome (HIV/AIDS), and transfer of hazardous materials and technologies. The sustainability of occupational health and safety structures and functions in the developing countries is a primary concern. Socioethical principles emphasize local, national, mutual and global gains. Examples of collaboration are given. Pervasive problems and strategies toward their solution are highlighted.

Women's occupational health in globalization and development.

BACKGROUND: The article describes the current process of globalization and its implications for development generally and for women, their work, and health. METHODS: The article outlines positive impacts in terms of enhancing employment opportunities in nontraditional spheres, and negative impacts in the growth of poor quality, insecure jobs with weakened social support systems. The case study of women's work within export processing zones is used to explore these conditions and their health impacts. RESULTS: The case study and other evidence provides a profile of work-related health that arises from a mix of patterns of employment, work processes, living conditions, and reproductive rights. CONCLUSIONS: The observed problems are poorly recognized, poorly studied for their combined causes and outcomes, and poorly regulated. The article explores and reviews how the patterns of female employment affect women's ability to collectively confront the causes of ill health and the challenges to improving women's occupational health in these conditions.

Health impact of occupational risks in the informal sector in Zimbabwe.

Information about occupational health in the informal sector is lacking, despite its growing contribution to employment. The author describes a survey of occupational health in urban and rural informal-sector workers in Zimbabwe. Common hazards included poor work organization, poor hygiene, ergonomic hazards, hazardous hand tools, and chemical exposures, particularly to pesticides and solvents. An annual occupational mortality rate of 12.49/100,000 was half the formal-sector rate. Reported rates of 131 injuries/1,000 workers and 116 illnesses/1,000 workers exceeded formal-sector rates tenfold and a hundredfold, respectively, although the distribution of injuries by economic sector correlated significantly with formal-sector rates. The survey found high levels of musculoskeletal and respiratory illness, thought to be underdetected in formal systems. A fifth of the injuries had resulted in permanent disability, with little consequent job loss, but no compensation granted. The author recommends improvements to occupational health in the informal sector, and suggests a broader survey of occupational morbidity in all sectors of employment.

Isolated Musculocutaneous Nerve Injury: A Case Report.

A case report of an isolated musculocutaneous nerve injury distal to the branch to the coracobrachialis muscle of the non-dominant arm is described. The injury occurred in the context of an industrial setting, specifically, an assembly plant. The non-dominant limb was injured; in contrast, most reports indicate the dominant limb was affected during strenuous activity. Nerve function was monitored with serial electromyography. Management of the injury was conservative, with eventual full functional recovery.

Estimating child mortality in Zimbabwe: results of a pilot study using the preceding births technique.

Using the preceding birth technique, 2,229 mothers were interviewed at four antenatal centres (two of which were urban) over a three month period during a pilot study in Zimbabwe. Results of the study showed that there was a small difference between the under two and under five mortality. The smaller than expected difference could have been due to some degree of urbanisation being experienced at two of the centres, and to a systematic selection bias of the method. Other findings of the study showed that younger mothers (under 20 years of age) and older mothers (over 40 years) experienced higher proportions of mortality, than mothers in the age group between. The higher proportion of male mortality compared to that for females reflected the expected trend, but the size of the difference was somewhat surprising, and could have been due to recall bias. The mean birth interval was 36 months, rather than the expected 30 months, and analysis of mortality in relation to birth interval and maternal age showed that a birth interval of less than 18 months was associated with higher child mortality, significantly so with the second last child, independent of mother's age. Longer birth intervals (more than three years) among older mothers were associated with higher changes of child survival. It is concluded that the Brass-Macrae method is a useful technique to analyse levels and trends of child mortality.

PIP: The University of Zimbabwe and the Zimbabwe Congress of Trade Unions tested the ability of the Brass-Macrae methodology (i.e., preceding birth technique) to estimate current levels and trends in child mortality. Interviews were conducted with 2229 mothers attending the prenatal clinics of the Mbare and Glen View polyclinics in Harare and of a provincial hospital (Marondera) and district hospital (Mutoko), both in Mashonaland East Province. The overall child mortality rate was 53/1000 of the last live births and 54/1000 of the second last live births. Some degree of urbanization and a systematic selection bias of the method may have contributed to the small difference between the two rates. Among last live births, the provincial hospital in Marondera had the lowest child mortality rate, while the Mbare polyclinic in the capital city of Harare had the highest (43 vs. 61). The difference in child mortality rates for last live births between urban and rural areas was slight, while it was much greater for second last live births (2 vs. 11 points). Among second last live births, the district hospital in Mutoko had the lowest rate, while the Marondera provincial hospital had the highest rate (39 vs. 64). Child mortality levels peaked in the mothers' age groups less than 20 (88 for last live births) and more than 40 (84 for last live births and 78 for second last live births). Among last and second last live births, boys were more likely to die than girls (64 vs. 42, p 0.05, and 64 vs. 45, p 0.05, respectively). This difference could have been due to boys being more frail than girls or mothers being able to better recall boys deaths, since boys are highly valued. The mean birth interval was 36 months, but the expected interval was 30 months. A birth interval of less than 18 months was significantly associated with higher child mortality among second last live births (p 0.001), regardless of mother's age. Birth intervals of more than 3 years were associated with the best child survival rates in every maternal age group (e.g., 30-34 years, 8 vs. 52-250). This pilot study showed that the Brass-Macrae method is useful to estimate child mortality.

Structural adjustment and health policy in Africa.

World Bank/International Monetary Fund Structural Adjustment Programs (SAPs) have been introduced in over 40 countries of Africa. This article outlines their economic policy measures and the experience of the countries that have introduced them, in terms of nutrition, health status, and health services. The evidence indicates that SAPs have been associated with increasing food insecurity and undernutrition, rising ill-health, and decreasing access to health care in the two-thirds or more of the population of African countries that already lives below poverty levels. SAPs have also affected health policy, with loss of a proactive health policy framework, a widening gap between the affected communities and policy makers, and the replacement of the underlying principle of equity in and social responsibility for health care by a policy in which health is marketed commodity and access to health care becomes an individual responsibility. The author argues that there is a deep contradiction between SAPs and policies aimed at building the health of the population. Those in the health sector need to contribute to the development and advocacy of economic policies in which growth is based on human resource development, and to the development of a civic environment in Africa that can ensure the implementation of such policies.

Antiepileptics and the development of congenital anomalies.

We are conducting a prospective cohort study of epilepsy and pregnancy to determine the nature and extent of adverse pregnancy outcomes in infants of mothers with epilepsy (IME). Women with epilepsy were enrolled no later than the first trimester and were matched with controls; their infants were examined at 8 weeks by pediatricians blinded to maternal status. A number of variables were compared between case and control infants: birth weight, length, gestational age, head circumference, Apgar scores, feeding difficulties, neonatal irritability, and presence of major malformations and minor anomalies. The number of minor anomalies per infant was greater for IME than for controls (mean, 5.05 and 3.65, p less than 0.0001 per infant, respectively). Prominent occiput was the only anomaly seen significantly more often in IME than in controls (p less than 0.05).

The impact of home monitoring and daily diary recording on patient status in cystic fibrosis.

An experimental home monitoring system for assessing the progress and planning changes in the care of patients with cystic fibrosis (CF) has been implemented at the University of Minnesota Cystic Fibrosis Center. One group of patients and families did daily recording of physical measurements and symptoms, and sent the diary to the data coordinating center weekly for analysis. The remaining patients were not part of the home monitoring program. Twenty-five patients were randomly selected from the home monitoring group. They were compared to an age- and sex-matched control group not doing home monitoring to ascertain if home self-measurement and daily diary recording, in the absence of any therapeutic intervention, produced any change in physical or psychological status, pulmonary function, or growth over a 4-year study period. Subjects ranged in age from 6 to 43 years. Clinical status was measured by the National Institutes of Health cystic fibrosis scoring system. Pulmonary function was assessed as percent of predicted forced vital capacity and percent of predicted forced expiratory volume in 1 sec (FEV1). Growth was analyzed as percent of predicted weight based on age-, sex-, and height-dependent equations. Psychological status was determined by self-assessment and referral for conseling. Only percent predicted FEV1 in the control group declined significantly. There were no statistically significant changes in any other measures either within or between diary and nondiary groups over the 4-year period.(ABSTRACT TRUNCATED AT 250 WORDS)

A pilot study of hyperbaric oxygen in the treatment of human stroke.

We administered hyperbaric oxygen or air in a double-blind prospective protocol to 39 patients with ischemic cerebral infarction. We interrupted the study when we noticed what appeared to be a trend favoring the air-treated patients, whose neurological deficits were less severe (mean +/- SEM score on graded neurological examination: air, 25.6 +/- 4.9; oxygen, 34.5 +/- 7.5) and whose infarcts were smaller (air, 29.0 +/- 12.2 cm3; oxygen, 49.2 +/- 11.7 cm3) at 4 months. The trend, we decided, was probably an artifact of the randomization process. Nevertheless, we chose not to resume the trial because the treatment was difficult to administer by schedule (for various reasons the treatment protocol was broken in 15 of the 39 patients), was poorly tolerated (eight of the 39 patients refused to continue treatments), and did not produce dramatic improvement.