Gender in Society

Zambia is a landlocked, resource-rich country with sparsely populated land in the centre of Southern Africa. It shares its border with eight countries (Angola, Botswana, Democratic Republic of the Congo, Malawi, Mozambique, Namibia, Tanzania, and Zimbabwe) that serve as an expanded market for its goods. Its population, much of it urban, is estimated at about 17.9 million and growing rapidly at 2.8% per year, partly because of high fertility, resulting in the population doubling close to every twenty-five years. (1) Girls and women continue to remain vulnerable because of many age- and sex-specific social barriers and gender inequalities. High Gender-Based Violence (GBV) prevalence in Zambia, particularly in rural areas, is due to existing cultural norms and unequal power relations at the household level. The 2013/14 Zambia Demographic Health Survey (ZDHS) reports that from all women who had experienced any type of physical or sexual violence, only 43% sought help to stop the violence, 9% never sought help but told someone, and 42% did not seek help and never told anyone. (2) Where help was sought, GBV survivors most frequently sought it from their own family (69%) or from the husband or partner’s family (43.2%), while formal structures of support were hardly approached for help (e.g., police – 7.8%; medical staff – 1.5%; social work – 2.2%). Unfortunately, there are no cases of sexual harassment in the workplace from any sector which have been referred to the National Prosecution Authority (NPA), except for one in the recent past.

Figure 30.1 Infographic Zambia. Infographics were provided by CartoGIS Services, The Australian National University. Population: from World Bank https://databank.worldbank.org/source/population-estimates-and-projections. Sustainable Development Progress, global ranking and statistics on women in the workplace, women in management and intimate partner violence: from United Nations SDGs Data Portal https://unstats.un.org/sdgs/dataportal. Female doctor percentage: from Global health workforce statistics www.who.int/data/gho/data/themes/topics/health-workforce. Legislation and law statements: from the World Bank gender data portal 2023 https://genderdata.worldbank.org/en/indicators. Maternal mortality statistics: from the Global Health Observatory 2020 https://mmr2020.srhr.org. Infant mortality statistics: from United Nations International Children’s Fund (UNICEF) https://data.unicef.org/topic/child-survival/under-five-mortality.

Figure 30.1Long description

The infographic provides information about Zambia, with a population of 20.6 million and 3.1 doctors per 10,000 people. It highlights several gender-related statistics. 52 per cent of women participate in the workforce. 40.5 per cent of women are in managerial positions. 41 per cent of women have experienced intimate partner violence. Maternal mortality is 135 per 100,000. Infant mortality under 5 is 5560 per 100,000. 81.6 per cent of doctors are women.

The infographic lists the presence or absence of law and policy on gender equality. In Zambia:

• – a woman can get a job in the same way as a man.

• – there is legislation on sexual harassment in employment.

• – there is legislation specifically addressing domestic violence.

• – the law prohibits discrimination in employment based on gender.

• – criminal penalties or civil remedies exist for sexual harassment in employment.

• – the law mandates equal remuneration for females and males for work of equal value.

The S D G Gender Index global ranking is 124, and there is some progress.

Gender in Medicine

There has been a notable change in the number of women in medicine in Zambia, from one female medical student entering medical school about fifty years ago to some universities recording over 50% female medical student entry recently. Despite this great achievement we have great underrepresentation of women at the leadership level in the health sector in general. Over almost sixty years of independence, there has been no female doctor who has ever served as Minister of Health. Those doctors that have been ministers are male. Zambia has ten provinces: all provincial health offices are headed by male doctors. It is almost the same picture at the district level, where we have less than 10% representation in the 110 districts. Women remain underrepresented at the various levels of leadership in the health sector in Zambia in research, academia and hospital management.

On the other hand, in the private sector, including private hospitals, non-governmental organisations and international organisations, female doctors are heading these organisations, some with more than 100 employees. One of the reasons women abstain from leadership positions in Zambia is because workplace policies do not support the parental and family roles that women have. Women are slowly getting more support from partners in our society but women in leadership roles need more than just supportive partners. Our workplace systems need to be more inclusive and diverse for us to see a meaningful change. Women in the health sector in Zambia continue to be underrepresented in positions of authority. They are merely restricted to lower ranks of management.

A recent study showed that firms with female CEOs experience 48.3% less sexual harassment. An increase of one female director is associated with a 18.2% decrease in the sexual harassment rate. (Reference Au, Tremblay and You3) Of course, more is involved in reducing sexual harassment in workplaces. Increasing female leadership in the health sector is one way to start through deliberate collaborative and innovative leadership.

Medical Education

For a long time, there was just one public medical school in the country, but in the recent past we have seen an increase in the number of both public and private medical schools. The duration of training for a medical doctor varies between six and seven years depending on the institution. There are also a number of medical students that train in other countries like China and Russia, after which they come back home to practise medicine. The faculty under these universities are responsible for assessing competencies both at undergraduate and postgraduate levels. All newly trained and inducted medical doctors have a mandatory one-and-a-half-year internship as junior resident medical officers. On completion they may choose to undergo specialty training for another four years on average in their field of choice or remain as general medical officers. Certain fields tend to attract more women for specialisation, like paediatrics, and obstetrics and gynaecology, although the overall number of males is always higher. Other than a few private hospitals and non-governmental organisations (NGOs), the government, through the Ministry of Health, is the main employer of all medical doctors in Zambia. However, at the hospital level, the hierarchy in the department starts with the head of department, consultants, senior registrars, registrars, then the interns, and learning in the clinical environment is by apprenticeship. Therefore, the seniors play a major role in the career progression of the junior colleagues because they impart skills and knowledge, and complete the appraisals of students and junior doctors’ performance, in the form of logbooks. This, unfortunately, means doctors in junior positions, including students, are vulnerable to hierarchical abuse. Culturally, a junior may never offer criticism or any form of feedback to the superiors regarding their clinical learning environment for fear of jeopardising their career progression. Even though there no actual studies to indicate the level of abuse in the Zambian context, other studies have found that inappropriate behaviour, harassment, and belittlement of physicians-in-training was perpetrated mostly by fellow physicians in superior positions. (Reference Szafran, Woloschuk, Torti and Palacios Mackay4)

Law

Zambia has laws which prohibit sexual harassment in the workplace. These are the Gender Equity and Equality Act no. 22 of 2015, the Anti-Gender-Based Violence Act no. 1 of 2011 and the Penal Code. These acts provide criminal and civil sanctions. (5) The law generally deals with cases of sexual harassment very seriously, as the offence has a very strict punishment with a minimum of three years’ imprisonment and a maximum of fifteen years’ imprisonment. However, the evidentiary rules in offences of a sexual nature are quite onerous as they require corroboration. The evidence of the victim has to be corroborated by independent evidence which tends to establish the identity of the perpetrator and the commission of the offence. These corroborative rules are in place to guard against the danger of false implications. These rules are onerous as most incidents of sexual harassment occur in private, and in the absence of evidence such as text messages or an eyewitness it becomes difficult to prove a case beyond reasonable doubt.

There are specialised police, prosecution, and judiciary departments mandated to deal with cases of sexual harassment; however, the evidentiary requirements are the major impediment that may lead to perpetrators not being charged. Victims can receive support from One Stop Centres, which offer multi-disciplinary support in the form of counselling and legal advice. The police and the prosecution service also provide counselling and legal support as do non-governmental organisations. There are risks of retaliation and further harassment on a victim who reports, as most institutions both private and public do not have safety mechanisms that protect a victim from backlash. The medical doctors do not have an institution mandated to defend them in civil or criminal cases nor do they have insurance which would cover such costs. Women who report sexual harassment are often viewed as weak or are blamed for having seduced the man, for example, by their way of dressing. Additionally, many panels to resolve such issues are led by men who are less knowledgeable about sexual harassment.

Medical Regulation

In order for medical doctors to practise in Zambia, they have to register with the Health Profession’s Council of Zambia (HPCZ). The Council has the mandate to register and regulate all health facilities in Zambia, both public and private, and training institutions teaching health sciences. The HPCZ is a statutory regulatory body established under the Health Professions Act No. 24 of 2009 of the Laws of Zambia. The functions of the HPCZ as enshrined in the Act, among others, include the registration of health practitioners and regulation of their professional conduct. (6)

Professional misconduct may warrant disciplinary action, as spelt out in the organisation’s ethical code of conduct which states in part that personnel (health practitioners) exhibiting dishonest behaviour or corrupt practices, and indecent or violent behaviour, may lead to disciplinary proceedings even if the offence is not directly connected with the health practitioner’s profession. Some of the disciplinary measures include cancellation of registration, censure or counsel to the practitioner or otherwise imposition of fines. (7) Clearly there is no mention of sexual harassment of colleagues in this document. The role of colleagues and other professional bodies is not clearly spelt out in how an erring member should be disciplined. On the progressive side, the Public Service Management Division (PSMD), which is the regulator of all public workers doctors, including doctors, has recently revised the disciplinary code and procedures for handling offences in the public service, as of May 2023. Any form of sexual harassment on first breach results in instant dismissal from public service. (8)

Prelude

Following ethics approval (#1652–2021), a survey using Google form documents that did not capture any personal information or identifiers was sent to the membership of the Medical Women Association of Zambia. Eight responded to the questionnaire and reported to have experienced sexual harassment, which happened between one to more than ten years ago. The sexual harassments which have been experienced by the survivors include inappropriate texting (3), inappropriate touching (3), inappropriate comments (7), physical contact (2) and rape (1). Three of the survivors are currently working in the same department as the perpetrators. Only one perpetrator was the same rank as the survivor, while the rest of the perpetrators were senior to the survivors at the time of the harassment.

Most survivors attributed organisational culture, followed by social context and personal vulnerabilities, as factors they thought contributed to the sexual harassment. Below are quotes from the survivors’ perspectives on what they consider put them at risk of such horrendous acts.

The Assault

Here we highlight the narratives given by two of the survivors.

One of the respondents (S5) narrated this.

However, this was plain simple: it was rape.

The second survivor (S6) explained an incident as having brewed from ward rounds.

At the end of each rotation, junior residents get signed out before rotating through another specialty. As this junior officer went to the head of department’s office to be signed off, he grabbed her and started touching her breasts and asked for sex; but she found a way to escape and never looked back.

Limbo

An analysis of the responses reveals an alarming trend of systemic sexual harassment by male doctors of female doctors who were in the majority of the cases subordinates of the perpetrators. More than half of the respondents considered reporting the case; however, only two did report. Reports were made to the immediate supervisor and to the Ministry of Health. In both cases nothing came out of the reports, one respondent was told that it was normal for new young doctors to be approached by seniors and in the second one the complaint report went missing. There were no sanctions, nor was accountability meted out on the perpetrators for the reported cases. The only satisfaction that respondents got from reporting was that they experienced no further acts of harassment.

The major challenges faced by the respondents which prevented reporting were fear of reprisals and of being labelled difficult, in addition, respondents thought they would not be believed. Previous attempts by other female doctors to report had resulted in the whole hospital knowing of the incident: the lack of confidentiality and protection against retaliation were major deterring factors for non-disclosure. Other key considerations were that respondents did not want to create work tensions with perpetrators with whom they still had to work. Moreover, the lack of documented evidence of incidents of harassment contributed to the non-reporting, as respondents believed their word alone would not suffice. Knowledge of whom to report to was not known to all: only half of respondents knew where to go. Some respondents hoped for the incidents of sexual harassment to naturally go away, and half of the respondents stated that they did not have the personal strength to report as the process of doing so would be cumbersome and emotionally draining.

Exposure

Two of the survivors reported that they had experienced retaliation from the perpetrators and colleagues. And as a result, the survivor had to leave that hospital and find employment elsewhere. Three survivors had actually experienced thoughts of how they would cope with a sense of betrayal in the event that colleagues talked about them, and one of these narrated that she did not care only for her career. On the other hand, another survivor narrated the ordeal her friend went through when she reported a rape case at her institution, and we infer here that this friend unfortunately did not participate in our current survey, and hence we cannot comment on the specifics of the experience. This loss of anonymity and gossip has some repercussions on how the survivors would cope with the sense of betrayal. This survivor did not report her case, and she does not think she would recommend anyone to report a rape case at her hospital.

None of the survivors in this survey ever thought they needed to respond to critics or people talking about them if it came to light that their cases were exposed. One of the survivors alluded to thoughts of self-blame and said people have often misunderstood her friendliness. On the contrary, another survivor knew she would be criticised but the critics would not be correct to blame her for being female around men who are ill mannered. Some of the survivors did consider how they would cope working in an environment amidst the gossip and would have preferred to get a transfer. While another actually moved:

Aftermath

After the incidents, the respondents expressed different feelings; some respondents felt the incident made them stronger. ‘I feel strong as I had a clear plan on how to gather evidence about the harassment and to report it.’ Another one responded, ‘A strong doctor.’ There was self-blame as well. ‘I always think I am a coward. I should have fought.’ Not reporting the incident meant they could go on without anybody knowing.

The impact the incident had on their personal and professional life was profound. It has led to suspicion and mistrust of male colleagues: ‘I am suspicious of male colleagues. I always prefer to work with female doctors on projects.’ A loss of respect as well:

Avoidance of male colleagues as well: ‘I am distant with male colleagues, and I am not usually comfortable in situations where I find myself alone with a male colleague.’

Respondents also described recovery in various ways that meant some state of forgetting, forgiveness or feeling comfortable about themselves and feeling comfortable in the company of male colleagues. Agonisingly, some have failed to recover. One described recovery as ‘Not happening as I see him with his smirk on his face.’ Others reached a place of recovery through counselling and prayer. Sadly, most have not fully recovered, and this remains a work in progress. Some respondents have used their experience to counsel others and raise awareness on the issue, seeking the benefit of others.