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Archive for June, 2015

Jogini Culture and HIV

5 Jun, 15 | by Kristy Ebanks

By Manasi Jiwrajka

The case report HIV in India: the Jogini Culture presents a case of a 32 year old Jogini from rural Andhra Pradesh who is HIV positive.

‘Jogini’, ‘Devadasi’ or ‘Mathamma’ are terms used to describe a girl committed to theogamy, or in other words, who is ‘married’ to a deity when she reaches puberty, and spends her entire life being sexually exploited by the deity’s priests or devotees. (1-3). Although similar practices have existed in many ancient European and Middle Eastern cultures, this practice is currently prevalent in Andhra Pradesh, a state in southern India. It is estimated that there are 16,799 documented Joginis in Andhra Pradesh and 22,943 Devadasis in Karnataka. (1)

Historically, the practice originated in medieval India when a woman “would become a Jogini in order to upkeep the services of the temple…sweeping the temples, and carrying the utensils for workship.” (1) However, the current practice involving sexual exploitation has emerged as a result of the caste system in India, and specifically due to “a schism [that] appeared between the ‘clean’ and the ‘unclean’ castes,” whereby the “Jogini from the ‘unclean’ castes were often pushed into the sexual exploitation,” and women from the ‘clean’ castes were somewhat protected by The Madras Act V of 1929 or the 1934 Bombay Devadasi Protection Act that “tried to emancipate the Jogini from their servitude.”(1) Whilst technically the practice is prohibited in India since Indian Independence, clandestine practices still exist, and in fact, some argue that the “efforts to abolish these practices since the days of British rule has increased the stigma attached to its victims and reinforced their risk of entry into commercial sex work.”  Today, all Jogini or Devadasis are Dalit, or “untouchables” from the lowest caste. (4)

Inherently, the Jogini culture is religious in nature but other cultural beliefs also play a role in the continuation of these practices. For example, Borick mentions that the patient’s father was worried about who would cremate him after his death, and his cultural beliefs dictated that “only a son could light his funeral pyre.” However, “since he did not have a son, he was in danger of becoming a ghost,” and as such he decided that if his daughter were a Jogini, “because of her special relationship to Goddess Yellamma, she would be able to light his funeral pyre when he died.”

Some of the Global Health issues that arise in this case are as follows:

1.       Poverty

2.       Lack of education

3.       Gender Equality and Women Empowerment

4.       Child Mortality

5.       Maternal Health

6.       HIV/AIDS

It is important to note that this one case of the Jogini raises 6 out of the 8 issues that are addressed by the Millenium Development Goals.

The patient’s father, as previously mentioned, decided that his daughter should be a Jogini compelled by his poverty and lower socioeconomic status as a Dalit (or untouchable). In his case, poverty prevented him from paying a dowry, a cultural practice that still exists in India, and as such, “the options for his daughter were limited.”

Due to this poverty, or perhaps as a result of a lack of education and literacy among Dalits in general (5), “the patient never attended school.” Dalit women “suffer from 17% more illiteracy” compared to women from other castes and “92.8% of Jogini” are illiterate. (1)

Education is intrinsically linked to women’s empowerment, child mortality, maternal health and HIV/AIDS. “Education is one of the most important means of empowering women with the knowledge, skills and self-confidence necessary to participate fully in the development process.” (5) Borick speculates that “perhaps even a few years of primary school would have provided [the patient] with literacy skills and the confidence necessary to seek an alternative way to earn a living,”(1) and had the patient been given educational opportunities, she would have had a different source of income.

Additionally, literacy and child mortality are linked as well: “in India, literate mothers have lower rates of severely stunted (40% compared with 44%) and severely underweight (7% compared with 9%) children when compared with illiterate mothers. For every 10% increase in female literacy in India, there is a 9/1000 decrease in the child mortality rate.” (1)

Similarly, there is evidence to suggest that educated mothers have better maternal health compared to those who are not educated, as they have “a greater spacing between pregnancies [and] the more education that woman has, the more likely she is to understand contraceptive methods taught by health workers including condom usage.” (1)

Safe contraceptive methods can prevent sexually transmitted diseases including HIV, which is “five times as high” (2.6%) in Devadasi districts compared to the state average (0.52%). Joginis and Devadasis, are at a higher risk of HIV and other sexually transmitted infections “due to high risk sexual activity.” Additionally, Jogini have a ten times higher mortality rate due to AIDS compared to the national average of women in India. (1)

Whilst the Jogini culture is known only in India, similar ‘ritual servitude’ practices exist in other countries; the practice is known as ‘deuki’ in Nepal or ‘trokosi’ or ‘vudusi’ in Ghana, Togo and Benin wherein “a female child, usually a virgin, is selected by her family to serve in a shrine in reparation for crimes committed by other members of the family.” (6, 7) Therefore, similar global health issues exist around the world where just like the 32 year old patient, women are sexually exploited, come from rural areas, with a lack of educational opportunities and suffer severe discrimination.

References
1. Borick J. HIV in India: the Jogini culture. BMJ Case Reports. 2014;2014.

2. Black M. Women in Ritual Slavery: Devadasi, Jogini and Mathamma in Karnataka and Andhra Pradesh, Southern India*. Pakistan Journal of Women’s Studies = Alam-e-Niswan = Alam-i Nisvan. 2009;16(1/2):179-205.

3.Misra KK, Rao KK. Theogamy in Rural India: Socio-Cultural Dimensions of the “Jogini” System in Andhra Pradesh. Indian Anthropologist. 2002;32(1/2):1-24.

4.Torri M-C. Abuse of Lower Castes in South India: The Institution of Devadasi. Journal of International Women’s Studies. 2009;11(2):31-48.

5. UNFPA. Report Of The International Conference On Population And Development. Cairo: UNFPA, 1994 1994. Report No.: (94/10/18).

6. Ameh RK. Child bondage in Ghana: A contextual policy analysis of trokosi [Ph.D.]. Ann Arbor: Simon Fraser University (Canada); 2002.

7.  CEDAW. Shadow Report on the 4th & 5th Periodic Report by The Government of Nepal on CEDAW. 2011

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Socioeconomic Privation & Congenital Birth Defects – Cause or Coincidence?

1 Jun, 15 | by Kristy Ebanks

By Kristian Dye

This week I’m looking at two very sad cases of stillbirth in Cali, Colombia.

When we think of disease caused by social circumstance we often imagine non-communicable diseases or infectious diseases, usually where poor living conditions loom large in the aetiology.

When we consider the higher rates of genetic birth defects in socially disadvantaged populations we often express our dismay at what rotten luck it is that this happens to people who are also poor. Here, we miss a key to understanding these diseases. The circumstance of being socioeconomically deprived can provide the conditions necessary for defects of the type in these cases to occur.

Sirenomelia is a rare congenital defect with a prevalence rate of around 1 in every 100,000 birth, and 300 cases have been reported in the literature. The aetiology and pathophysiology of the defect is not well understood, but is thought to be related to vascular abnormality.

‘The vascular steal hypothesis suggests the existence of an anomalous vessel impeding proper blood flow to the caudal end of the embryo. One of the most important early findings in prenatal imaging is a SUA [single uterine artery] of abnormal origin, with SUA of vitelline origin being considered characteristic of sirenomelia.’

There are a number of known risk factors associated with sirenomelia, including maternal diabetes and exposure to teratogenic drugs (such as anti-convulsants or retinoids). Neither mother had abnormal glycaemic control, and neither had been exposed knowingly to teratogens. Incidence of sirenomelia appears to decrease with advancing maternal age – and both women were in the non-increased prevalence group. The only common risk factor between the women was their access to water. Both women relied upon a nearby river for their water – a river which is known to be contaminated with leachate from landfill.

‘During their normal daily activities they were exposed to the river that flows near their homes, where they would wash their clothes and perform personal hygiene activities.’

The contaminated water is known to affect changes in the fish population. The women lived less than 2km from one another. There is a large amount of literature which has observed a correlation between socio-economic status and increased incidence of congenital abnormality – and in particular between proximity to landfill and deformity. One study, of centers in the UK, found that the relative risk of non-chromosomal abnormalities increased by 40% between the most affluent quintile and the most deprived. Where the literature perhaps underestimates the effect at the level of the global population is that the majority of studies are based in the North America or Europe, where socioeconomic deprivation is less relative to the global standard, and where there is a great deal more environmental regulation than elsewhere in many other parts of the world.What is clear, however, is that we can’t think of socially determined health in simple terms of diseases that are transmitted within poor conditions, or are developed as a result of poor nutrition, education or living conditions. Children can be born with disability and disease as a result of the conditions their mothers live in.

1. http://casereports.bmj.com/content/2015/bcr-2014-207543.full?sid=a42f459e-cacf-4e28-b0ca-e50f05aef649
2. http://www.jneonatalsurg.com/documents/vol-1/pdf/jns-2012-1-2.pdf
3. http://m.aje.oxfordjournals.org/content/167/2/145.full.pdf
4. http://www.ncbi.nlm.nih.gov/pubmed/21689813
5. http://www.marchofdimes.org/materials/global-report-on-birth-defects-the-hidden-toll-of-dying-and-disabled-children-full-report.pdf Page 23
6. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(98)01352-X/fulltext
7. http://www.sciencedirect.com/science/article/pii/S0140673602075311
8. http://adc.bmj.com/content/82/5/349.full.pdf

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