World in the Balance homepage

"Reproductive health" is an oxymoron for many poor young women in Africa. To get by, even to get a meal, many are forced to offer sex to "sugar daddies" in exchange for food or money. In the process, these women, many of them in their teens, regularly contract HIV/AIDS and, when they turn to illegal backstreet abortionists to terminate unwanted pregnancies, often wind up in the hospital or, worse, the morgue. Despite this tragic picture, Pamela Onduso, a Nairobi-based reproductive-health expert for Pathfinder International, holds out great hope for improving the reproductive prospects of young people in Kenya and elsewhere in Africa. Find out why in this interview.

Teenage troubles

NOVA: In human history, this is the biggest population of young people ever. What risks do they face in today's world as they enter their sexually active years?

Onduso: The risks that young people face are many. These include unprotected sex that leads to unintended pregnancy as well as to contracting HIV/AIDS. There are other factors, including unemployment, particularly for those who are forced to drop out of the school system, and insecurity, particularly for young men and women who find themselves on the street, and therefore not in very safe circumstances, having to fend for themselves. I believe young people today face more challenges, more pressing needs, than ever before.

NOVA: Why is that?

Onduso: Because, for one thing, as you have said very correctly, we now have the largest ever group of young people on every continent. Africa is special in the sense that we have the largest percentage of young people in our total population of any continent. Over half of Kenya's 31 million people—that is, more than 15 million—are aged under 15 years. That creates special problems for Kenyan society.

NOVA: What kind of problems?

Onduso: A burden is being put on those in their reproductive years, those who are working to support very many younger persons. This is particularly true when you consider that, also in Kenyan society, our young women are having more children than ever before. Demographic and health surveys reveal that a third of young women have already had a child by the age of 18. In the age group 15 to 24, half of them have already had a child. This presents tremendous problems for the public-health and education systems as well as in the area of employment.

NOVA: I'm unclear—what are the consequences for the educational system?

Onduso: You just have to look at the splits between the number of males in Kenyan high schools—or secondary schools, as we refer to them here—versus the proportion of young females. Where you have a 50-50 split between males and females in elementary school, when you get to secondary school, because of pregnancy and because of families diverting resources to look after the male child, you find that you have only 25 percent of the class being female and three quarters being male.

“Young women are literally selling sex for favors. Sometimes it’s for something as simple as a meal, or even just a bag of chips.”

By the time they get to university, if you look at the statistics for our public institutions here in Kenya, you have a very dismal figure of 10 to 30 percent of enrolled students being female. In science faculties, you find it's almost negligible, something like 10 percent. This is unfortunate in countries such as ours that need to have scientists of both sexes, and in all the disciplines—because we do need to develop our societies, and we can only do so when we have young women participating as much as young men.

NOVA: Does poverty exacerbate this situation?

Onduso: In my view, based on my experiences working with young people in Kenya and in other countries of Africa, poverty is probably the major factor fueling the HIV/AIDS epidemic on our continent. As you are well aware, three quarters of reported cases of HIV are in sub-Saharan Africa.

Also, because of the preference for educating the male child, the young woman very often loses out, because she is supposed to be raised and married off. And when these young women are forced to drop out of school—very often with very basic elementary education—because the family doesn't have sufficient resources to educate both them and their male siblings, these young women wind up on the streets, and they sell their bodies in order to fend for themselves. This has created tremendous problems for us as a society, because young women are literally selling sex for favors. Sometimes it's for something as simple as a meal, or even just a bag of chips.

It is this sort of poverty that, in my view, is driving and will continue to fuel the HIV epidemic in this part of the world.

Sugar daddies

NOVA: For poor women, then, it often seems to be a matter of survival to have relationships with men.

Onduso: Women have sex with older men primarily for purposes of surviving, yes. Very often they're hungry and therefore need to get a meal. Sometimes it's for school fees. They need someone to pay for their education because their parents are unable to or have diverted resources to pay for a male sibling, who they see as someone who is likely to remain a part of the family, whereas the young woman is supposed to be married and essentially sold off later on in life. Therefore they don't see why they should spend too much money educating someone who is ultimately going to leave the family homestead.

“We have unintended pregnancies happening amongst our schoolgirls.”

Very many young women also engage in sex with older men because their peers are doing it. So there is an element of peer pressure. Sex does begin early in this country. Amongst urban young people, it begins at 13 for boys and a year later for girls. The consequences of this are very severe, both for the public health system and for the educational system.

NOVA: This is what's known as the "sugar daddy" phenomenon?

Onduso: Yes. The sugar daddy phenomenon is very common in Africa. It relates to older men having and maintaining younger women and using money to keep them as friends, very often as sexual partners. We even have a name for it here in Kenya. We call women who are maintained by these older men dogo-dogo, which means, in slang Swahili, "the little something that he keeps at his side." In the West you'd refer to them perhaps as concubines.

NOVA: What impact does this phenomenon have on young women in Kenya?

Onduso: It has created tremendous problems for our young women. Those who have grown up in systems that are very patriarchal and that have encouraged young women to basically accede to every request, sexual or otherwise, because the person asking is male, find it very, very difficult to negotiate even safe sex with these older men. Consequently, HIV/AIDS is being spread through this phenomenon. And we have unintended pregnancies happening amongst our schoolgirls, and God knows we need to have as many girls as possible go through the formal education system and wind up in university so that they can be economically independent.

NOVA: Is progress being made in curbing the phenomenon?

Onduso: It took us time to dig ourselves into that hole, and it's going to take us time to get out of it. In the meantime, we have a population of young women who have to eat, have to live, and, because of that, we know that we will have to continue dealing with this phenomenon of sugar daddies. And, to be fair, sugar mommies; it works both ways. We're going to have to deal with both of these phenomena very, very aggressively.

Poor abortions

NOVA: How and where do these young women get abortions? What methods do they use?

Onduso: Typically, in Kenya, young women access abortion services in backstreet alleys through people who are untrained. The methods they use are crude. We've heard of young women using coat hangers, knitting needles, detergent, and overdosing on antimalarial medication. We have horrifying stories of young women drinking concoctions of herbs given to them by a traditional healer in the village. God only knows what they put into those drinks.

NOVA: These women who come into the Kenyatta High Risk Clinic, what sort of damage are you seeing?

Onduso: By the time the young women show up at a public health facility—and I will talk about Kenyatta National Hospital, where Pathfinder for many years had a program working with young women who were admitted with complications of incomplete aseptic abortion—very often they're bleeding, they're septic, they're delirious, and they're traumatized. Because they have vaginal bleeding, typically the hospital will immediately admit them to the acute gynecological ward and complete the procedure, provide them with antibiotics, and initiate counseling.

“You can see that we’re sitting on a time bomb.”

The hospital recognizes that if they release a young woman who has been admitted with this complication without providing the necessary counseling, she will be back. This is what they found in the late '80s, that 30 percent of the young women who were admitted with incomplete or septic abortion would come back the following year with exactly the same problem. Which means they were using abortion as a method of family planning, which in our view is unacceptable.

NOVA: Are there high rates of morbidity because of septic abortions?

Onduso: Septic abortion, as the data here in Kenya shows, contributes to up to half of maternal mortality in this country, and therefore, it is a public health problem of significant proportions. It's one of the reasons why the Kenya government saw fit, beginning in the late '80s and early '90s, to begin to address the whole issue of post-abortion care. It recognized it was losing a significant proportion of its women to this unfortunate situation.

NOVA: But it hasn't cured the problem yet. It's still there.

Onduso: This is true. We are a growing nation, and unfortunately the government does not have sufficient resources to address every health problem, because, as you are aware, we also have to deal with issues such as malaria and HIV/AIDS. These, in recent years in particular, have overshadowed the public health crisis that the abortion issue has created. However, nongovernmental organizations and groups that are interested in preserving women's lives have continued to focus on providing a better quality of care for young women and older women as well in the area of abortion.

Impact of the gag rule

NOVA: How has the gag rule affected some of these programs? [Under the global gag rule, which was reinstated by President George W. Bush in January 2001, foreign family-planning agencies may not receive U.S. assistance if they provide abortion services or lobby to keep abortion legal in their country.]

Onduso: The gag rule has been deleterious to our work. One of the immediate effects for us here in Kenya was that we saw our family-planning program shrink dramatically, and we saw a shift amongst our donors away from family planning to focus more on HIV and AIDS. We are happy that reproductive health remains a focus, even with donors, but our programs, particularly those that were primarily family planning focused, had to close.

This had an impact on initiatives that were very good and that contributed to the declines in fertility that we saw as a result of family planning. In the 1980s in Kenya, the average woman had eight children, and by the end of the 1990s, the average woman in Kenya had four, both rural and urban. Those significant declines, something that has never been seen anywhere else in the world, are now being reversed because we are not focusing on family planning. We know that there is an unmet need for family planning, and that this will only grow. Add to this the fact that you now have more and more young people entering their reproductive years, and you can see that we're sitting on a time bomb.

NOVA: How so exactly?

Onduso: The time bomb I'm talking about is the fact that we have more and more young people entering their reproductive years. They will need to have access to family-planning information, education, and services. If we do not address their very pressing needs, we will see a rise in the number of young women who have unintended and unplanned pregnancies and find themselves single parents. We'll also see an increase in the number of young women who will probably die, because they will attempt to procure an abortion, very often using the cheapest option, which is unsafe.

“We have a saying in Kenya that loosely translated from the Swahili means ‘all things are possible.’”

We'll also have very many young men who will need to make a living for themselves and, perhaps because they're not in the school system, will turn to crime. This will only increase insecurity in our nation. Therefore, it is extremely important for us to address the issues around family planning, not just for the older adults in our society but also for our young people, before it's too late.

Holding out hope

NOVA: What needs to be done to help these teens get the right contraceptives, the right educations, to stop the increased spread of HIV? Are you hopeful that things can change?

Onduso: I'm extremely hopeful for Kenya's young people, for many reasons and on many fronts. We have a saying in Kenya that loosely translated from the Swahili means "all things are possible." As we speak, we have new government. We have a Minister of Health who is committed to reproductive health issues, and I believe that sometime before the end of 2003, we will have in place the first-ever adolescent reproductive health and development policy, which will basically set a framework for provision of reproductive health for young people in Kenya. This is a major milestone for those of us who work in reproductive health and who work with and around young people, because, for the first time ever, we actually have a framework under which we can provide services to our young people.

The second reason I believe there is a reason for hope is the mere fact that, in Kenya, we are recognizing and beginning to mainstream gender as an issue in all of our reproductive health programming. I know for a fact that the Ministry of Health has already included gender mainstreaming in its five-year strategic plan, and they are to be commended for having done that.

Thirdly, we are very hopeful as Kenyans that this is the time when we will be able to scale up the small, pilot programs that we have been using to provide reproductive and other services to young people.

Fourthly, amongst the local community here in Kenya there is recognition that, for example, the corporate sector needs to play a more active role in development. One of the most exciting things we've seen this year is the active participation of corporations and the HIV and AIDS Business Council here in Kenya, working in partnership with nongovernmental organizations to fill the gaps in our programming. Specifically, they're helping us in terms of provision of food in our programs, for example, to HIV/AIDS orphans. And they're helping us in provision of vocational education to young people, so that we can give them a livelihood and a hope.

Finally, I believe that we nongovernmental organizations need to focus and will continue to focus on the young people who are out of school, who form the majority of the young people whom we see, and to provide them with life skills, skills that will enable them, through tailoring, carpentry, hairdressing, photography, or basic mechanical and artisanry skills, to earn a living and keep themselves off the streets and out of trouble.

NOVA: What sort of programs do you think are most successful in reaching young people?

Onduso: One of my favorite programs has to be Mathare Youth Sports Association, which reaches out to young men using soccer as the entry point. They have very cleverly managed to include reproductive health education and training for all of their young men engaged in sports—and now, because they have a women's league, all of their young women as well. It's been a very, very important factor in their success. I gather that they are now up for the Nobel Peace Prize for this year in recognition of the success of that very exciting program.

When it comes to young women, we do have to make special efforts to get them to come to take part in programs, because very often their lives are very closely tied to domestic chores. And unfortunately you also have to spend a lot more time with their parents and minders, so to speak, to convince them that these young women are being taken to a place where they are going to be trained in useful skills that will contribute to the family income.

Having said all that, I would say that the future does look very, very promising for both sets of young people, because those of us involved in programming have been at it long enough to know what works and what doesn't.

Read more interviews