RESEA R C H ART I C L E Open Access
Health and human rights of women imprisoned
in Zambia
Katherine W Todrys and Joseph J Amon
*
Abstract
Background: The healthcare needs and general experience of women in detention in sub-Saharan Africa are rarely
studied and poorly understood.
Methods: A mixed-methods study was conducted including in-depth interviews with 38 adult female prisoners
and 21 prison officers in four Zambian prisons to assess the health and human rights concerns of female
detainees. Key informant interviews with 46 officials from government and non-governmental organizations and a
legal and policy review were also conducted.
Results: Despite special protection under international and regional law, incarcerated women’s health needs–
including prenatal care, prevention of mother-to-child transmission of HIV, and nutritional support during
pregnancy and breastfeeding–are not being adequately met in Zambian prisons. Women are underserved by
general healthcare programs including those offering tuberculosis and HIV testing, and reported physical and
sexual abuse conducted by police and prison officers that could amount to torture under international law.
Conclusions: There is an urgent need for women’s healthcare services to be expanded, and for general prison
health campaigns, including HIV and tuberculosis testing and treatment, to ensure the inclusion of female inmates.
Abuses against women in Zambian police and prison custody, which violate their rights and compromise their
health, must be halted immediately.
Background
In African countries, female prisoners comprise between
one percent (in Burkina Faso) and 6.3 percent (in
Mozambique) of the total convicted population [1]. Like
their male counterparts, women in African prisons fre-
quently face overcrowded and unsanitary conditions
conducive to poor health and the spread of infectious
disease [1]. Yet women are also confronted with unique
challenges–related to menstruation; pregnancy and
childbirth; care for children both inside and outside of
prison; and violence and abuse (including sexual abuse)
by prison officers or male prisoners with whom they are
sometimes held [1]. Women prisoners often have
experienced violence and sexual abuse prior to incar-
ceration, and may suffer from post-traumatic stress dis-
orders while detained [2]. Despite recognition of these
challenges, there has been little research on this popula-
tion to date.
In Zambia, female inmates comprise approximately 1.5
percent of the total prison population, with an estimated
250 female prisoners incarcerated nationwide in March
2011 [3,4]. While one of Zambia’s86prisonsisdedi-
cated exclusively to female inmates, and housed 66
women in March 2011 [4], women live in separate sec-
tions of prisons located throughout the country.
In addition to the international human rights law pro-
tections afforded to all prisoners and all women, female
detainees benefit from special legal protections. African
regional law, for example, provides that women in
detention should be held in an environment “suitable to
their condition”and ensures their right to be treated
with dignity [5]. The Southern African Development
Community Protocol on Gender and Development,
which Zambia has signed, commits states by 2015 to
“ensure the provision of hygiene and sanitary facilities
and nutritional needs of women, including women in
prison”[6].
This study examines women prisoners’experiences of
imprisonment in Zambia, with particular emphasis on
* Correspondence: amonj@hrw.org
Human Rights Watch, New York, USA
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© 2011 Todrys and Amon; licensee BioMed Central Ltd. This is an Ope n Access article distributed under the terms of the Creative
Commons Attri bution License (http://creativecommons.org /licenses/by/2.0), which permits unrestricted use, distribution, and
reproductio n in any medium, provided the original work is properly cited.
access to HIV and tuberculosis (TB) prevention, testing,
and treatment, women’s unique healthcare needs, and
treatment in police and prison custody. The main objec-
tive of the investigation was to document and respond
to specific human rights issues, monitor human rights
conditions, and assess human rights protections in Zam-
bian prisons. Analysis of male inmates’conditions of
detention and the criminal justice system attributes
leading to their extended detention in Zambian prisons
has been published elsewhere [7,8].
Methods
In July 2009, the Prisons Care and Counselling Associa-
tion (PRISCCA) of Zambia sought approval from the
Zambian Ministry of Home Affairs and Ministry of For-
eign Affairs for a mixed-method study of health condi-
tions in Zambian prisons. In September 2009 both
Ministries granted permission. Between September 2009
and February 2010, researchers from PRISCCA, the
AIDS and Rights Alliance of Southern Africa (ARASA)
and Human Rights Watch conducted in-depth inter-
views with female prisoners in four Zambian prisons:
Lusaka Central Prison (Lusaka province), Kamfinsa State
Prison (Copperbelt province), Mumbwa Prison (Central
province), and Choma State Prison (Southern province).
In each prison visited, researchers requested from the
officer in charge a private location to conduct inter-
views. Officers identified prisoners who were then pro-
vided by researchers with a verbal explanation of the
research (in English or French, and translated into
Bemba, Nyanja, or Tonga if necessary), asked if they
were willing to participate, and offered anonymity. Indi-
viduals were assured that they could decline to partici-
pate, end the interview at any time, or decline to answer
any specific questions without negative consequence.
The names of all prisoners who participated in this
study have been changed to protect their anonymity and
security. Responses were recorded in written notes and
all interviews were conducted outside of the hearing of
prison officers and other prisoners, in a private setting.
TheZambiaPrisonsServicedidnotpermittheuseof
recording devices.
Interviews took approximately 45 minutes and were
conducted in English or French by female researchers
from one of two organizations (Human Rights Watch or
ARASA) or in Bemba, Nyanja, and Tonga, with transla-
tion to English provided by members of PRISCCA.
Interviewers used a brief verbal questionnaire to gather
information on the prisoner’s incarceration history,
medical care, and experience of HIV/AIDS and TB test-
ing and treatment. Researchers then probed responses
and asked further questions regarding prison conditions,
discipline, and HIV/TB risk behavior in open-ended, in-
depth interviews.
Qualitative prisoner data were hand-coded by the
authors, who conducted a content analysis to identify
key themes corresponding to the interview guide, as
well as emergent topics. In the first analysis of the data,
an initial set of codes was generated to capture key con-
structs. Subsequent analyses were undertaken to exam-
ine the consistency of reports across themes and
examine negative evidence [9].
At each facility visited, researchers also requested
interviews with the officer in charge, deputy officer in
charge, medical officer and female officer in charge;
additional officers were invited to participate if sufficient
time allowed. Prison officers were provided with an
explanation of the purpose of the study and how the
information obtained would be used; they were given
the opportunity to decline the interview or to end the
interview at any time. Prison officer interviews focused
on HIV and tuberculosis testing and treatment availabil-
ity in the prison, healthcare delivery, deaths in custody,
prison administration, prisoner discipline and treatment,
and prison officers’working conditions.
Interviews with key informants from government and
national and international non-governmental organiza-
tions (NGOs) were also conducted, prior to and follow-
ing prison-based interviews, to identify salient issues and
probe specific findings raised in the research.
In addition, national legislation and policy governing
the administration of the prison and criminal justice sys-
tems were reviewed. Researchers reviewed all existing
Zambian legislation, extracting relevant portions related
to prison administration, criminal procedure, criminal
law, and immigration law. All available national policies
related to HIV/AIDS, health, and prison administration
were also examined.
Human Rights Watch does not generally identify its
work as “research”, defined as seeking to develop “general-
izable knowledge”[10]. Rather, its investigations aim to
document and respond to specific human rights issues,
monitor human rights conditions, and assess human rights
protections in Zambian prisons. Each of these purposes is
consistent with what has been defined as “public health
non-research”[11] or practice [10]. However, because
public health non-research and practice also raise ethical
and human participant protection issues, all investigations
conducted by Human Rights Watch are subject to rigor-
ous internal review, and external ethics and subject-area
experts are consulted when investigations involve particu-
larly difficult settings, populations, or issues. The present
study’s methods, and human participant protections asso-
ciated with the research, were reviewed by PRISCCA,
ARASA, and Human Rights Watch prior to undertaking
this study, and all interviewers were trained in human par-
ticipant protection and information security. Following the
interviews, and after initial reports of the study had been
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released, PRISCCA and Human Rights Watch continued
to monitor to ensure no adverse consequences to subjects
from participation.
Results
Thirty-eight adult female prisoners from four Zambian
prisons were interviewed, including 20 convicted, 14 pre-
trial, and four immigration detainees. Their ages ranged
from 22 to 77 years, with an average age of 37 years.
Thirty-two of the 38 women (84 percent) were of Zam-
bian nationality. Female prisoners interviewed reported
having been detained at the facility at which they were
interviewed for an average of nine months (with a range
from zero to 44 months). Twenty-one (55 percent) of the
women had reached secondary-level education or higher,
while six (16 percent) had received no education and 11
(29 percent) had only a primary-level education. In addi-
tion, 22 prison officers and 18 Zambian government offi-
cials from relevant ministries were approached for
interviews; one prison officer declined. Twenty-eight
representatives from local and international NGOs and
donor governments and agencies were also interviewed.
General Conditions
Women in Zambian prisons live in conditions of severe
overcrowding. Zambian prisons are over 300 percent of
capacity, and female inmates reported sleeping four to a
mattress, packed together in unventilated cells with
young children and the sick [12]. As one female inmate
reported: “Our cells are normally stuffed. There is no
ventilation, no windows. The sick and healthy are mixed
up. There are those with diarrhea. We are breathing the
same air”[13].
Both prisoners and prison officials reported that the
food provided by the government to prisoners is insuffi-
cient and nutritionally inadequate. Prisoners rely on
their relatives to supplement the meager food rations or
trade work for food. As one female inmate noted,
“Some people have no relatives–if you have no food,
you are nobody in this place. You can trade a cup of
sugar for work”[14].
The Zambia Prisons Service does not provide inmates
with basic necessities including soap, toothpaste, or sani-
tary pads. As one inmate noted, “If others don’tbring
them for us, we have nothing. There are lots of people
with no relatives here. They have nothing”[14]. Female
prisoners reported that sanitation and hygiene are poor,
and water frequently unclean. “It tastes foul, but we drink
it”, stated one female HIV-positive inmate [15].
In April 2010 only 14 health personnel served 16,666
prisoners, and of Zambia’s86prisons,only15hadany
health clinic or sick bay [3]. For those at prisons with-
out a clinic–and for those with more serious medical
conditions at those with a clinic–access to care is con-
trolled by medically unqualified and untrained prison
officers. According to prisoners and prison officers, a
lack of adequate prison staff for the transfer of sick
prisoners, inadequate vehicles for transportation and
fuel, and security fears keep inmates from accessing
medical care outside of prisons, in some cases for weeks
after they fall ill. As one inmate reported:
“There are delays in getting to the clinic. It depends
ontheofficials,iftheywanttotakeyouthereor
not. Sometimes you can go as long as a month wait-
ing to go to the clinic....They don’t open the door in
the cell at night for anything. There are no windows,
no air. Someone who was 28 years old died at night
in my cell and they didn’t open the door until the
morning”[16].
Pregnancy and women with children
International standards dictate that for women in deten-
tion, there shall be “special accommodation for all
necessary prenatal and postnatal care and treatment”
[17]. Zambia Prisons Service policy requires that
“Women inmates, including those who are HIV infected,
should receive...[p]rovision of antenatal care services as
offeredtoallwomeninthegeneralpopulation”[18].
But although prenatal care is widely available in the
Zambian general population [19], incarcerated pregnant
women interviewed described inadequate, and in some
cases non-existent, prenatal care. One pregnant woman
reported: “I had no initial exam when I came to the
facility, even though I am pregnant. There is no special
treatment for pregnant women, I take whatever I can”
[20]. Another female inmate, who reported she was six
months pregnant, said:
“I have not been to the clinic yet, no antenatal care.
I went to the clinic once but was told the nurses
were not working. Since then I have not asked. I do
not feel well, lots of ups and downs”[21].
For some prisoners, prenatal care existed but did not
meet international standards. The World Health Organi-
zation (WHO) protocol for prevention of mother-to-
child transmission (PMTCT) of HIV notes that “[a]ll
HIV-infected pregnant women who are not in need of
ART [antiretroviral therapy for HIV treatment] for their
own health require an effective ARV prophylaxis strat-
egy to prevent HIV transmission to the infant. ARV pro-
phylaxis should be started from as early as 14 weeks
gestation”[22]. However, one female prisoner, who was
eight months pregnant, reported:
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“I had VCT [voluntary counseling and testing for
HIV]–they tested my blood again and told me I was
HIV-positive.TheytoldmemyCD4courtwastoo
high for ART. I wasn’tgivenanyHIVdrugstopre-
vent transmission, only folic acid and vitamins”[23].
Indeed, there is no PMTCT program under the
prison medical directorate, though PMTCT programs
have been scaled up in recent years in the general
population. The estimated percentage of women in
Zambia’s general population living with HIV who
received ART for prevention of mother-to-child trans-
mission increased between 2004 and 2007 from 18 to
47 percent [24].
Inadequate nutrition is a serious problem for pregnant
women and women with children in prison. Prisoners
across facilities reported that meals consisted of
approximately 400 to 450 grams of maize meal per day
(400 grams of maize meal is equivalent to roughly 1,400
calories [25]), in addition to small quantities of beans
and/or kapenta (tiny fish commonly eaten in Zambia).
Normal-weight pregnant women require between 1,900
and 2,500 calories per day during the last six months of
pregnancy for healthy weight gain [26]. Yet there is no
special diet for pregnant women or for women who are
nursing.
Despite international standards calling for special pro-
visions for children incarcerated with their parents [27]
and Zambian law, which states that, “the infant child
[up to age four years] of a woman prisoner may be
received into the prison with its mother and may be
supplied with clothing and necessaries at public
expense”[18,28,29], the Prisons Service allocates no
food to children who live with their mothers in prison
facilities. In situations where women are unable to
breastfeed, the prison does not offer infant formula. As
the officer in charge at one prison reported: “Igetno
budget for the children’s food, they must eat their
mothers’food. They are hungry a lot”[30]. As the incar-
cerated mother of a nine-month-old boy said:
“My child is not considered for food–I give my share
to the baby, beans and kapenta–we each eat once a
day. I am not given any extra food, and no special
dietforthechild.Isimplymakesomeporridgefor
him out of my nshima. The baby has started losing
weight and has resorted to breast milk because the
maize meal is not appetizing”[31].
Another female inmate said: “I am worried about the
children who are here. There was a baby who died.
They don’t pay any particular attention to the children.
They are mixed in with everyone, they don’thavetheir
own cell or better food”[21].
HIV and TB testing
HIV and TB are major health threats for the entire
prison population–when last measured in 1999, HIV
prevalence was 27 percent for the Zambian prison
population, and 33 percent among female inmates [32].
Whereas TB prevalence was estimated to be 0.3 percent
in the Zambian general population in 2009 [33], a 2000-
2001 study in 13 Zambian prisons estimated the preva-
lence of pulmonary TB to be between 15 and 20 percent
[34]. HIV testing and treatment are offered at six pris-
ons nationwide with the assistance of an NGO, and as
of March 2011, prison-based TB screening and treat-
ment were offered only at three prisons nationwide as
part of a pilot program. For both diseases, researchers
found that female inmates were less likely to have been
tested than their male counterparts [8].
Female prisoners face potential breaches of consent
with HIV testing. The National HIV/AIDS/STI/TB Pol-
icy requires that women considering having a child be
encouraged to seek counseling and testing and ensures
that every pregnant woman has access to HIV/STI
screening and treatment. It does not require mandatory
prenatal testing [35]; Zambia Prisons Service policy pro-
hibits compulsory HIV testing [18]. However, interviews
with prison officers suggested that this prohibition was
either not understood or not respected for female
inmates. One prison officer said: “For those who are
pregnant, they are tested for HIV....Whether you like it
or not you are tested to prevent transmission to the
baby”[36].
Abuse of female inmates in police and prison custody
Female inmates, particularly women previously held in
police custody, reported physical and sexual abuse indi-
cative of a widespread and systematic pattern of brutal-
ity. Prisoners repeatedly reported that they were beaten
in police custody in order to try to coerce a confession,
often leading to serious injuries. One female inmate
who had previously been held in police custody, said:
“When I was in police custody, they beat me, a tor-
ture I have never experienced in my lifetime. They
beat me, undressed me, whipped me. They put
handcuffs on me so hard that the blood couldn’t
flow. They turned me upside down and hung me
upside down, with a steel cord between my legs.
They swung me and beat me. They saw I was crying
and screaming and put a cloth in my mouth to suf-
focate me. I fainted–I couldn’t handle the pain. They
were abusing me with their language, calling me a
prostitute. They put me somewhere where I couldn’t
talk to anyone. They were trying to get me to say
something–Idon’t know. They were just torturing
me for four days, beating me. After, there was lots
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of blood where I was beaten. My hands were green
and swelling.
They hit me on my ears and face with a metal band.
There were scratches on my face. They said, ‘you
have to give us information about who had killed
the person’. They tried to find out who had killed
the person–Ididn’tknow.Thepolicearesupposed
to investigate a case, not to torture.
After, they were scared to take me to a doctor
becauseIstillhadinjuries.Theyonlytookmeafter
one month, when the swelling was down. When I
went to the doctor, the police [officer] followed me
into the doctor’sroomandlistenedtome.The
police told the doctor that I was lying. ‘Just a simple
torture that she was given, not much,’he said”[13].
Several female detainees reported that police officers
tried to coerce them into sex in exchange for their
release. One female prisoner who had been detained in
police custody reported:
“They arrested and they beat me, asking questions.
They beat me up when I said I didn’t know any-
thing. They said, ‘we want you to say this, then we
will let you go.’They didn’t sexually abuse me, but
they asked me to have sex with them. They said
they would release me if I did, and I said no”[37].
Female inmates also reported particularly brutal forms
of punishment that they were subjected to once incar-
cerated in prisons. Women in prison were subjected to
beatings by their fellow inmates at the instigation of the
officers:
“When I arrived here, the officers shouted to the
inmates to say, ‘the woman coming is a witch, a
murderer–deal with her!’Shouting ‘you witch, you
murderer,’they rose up, hitting me. The officers just
watched. My injuries were largely bruises and swel-
lings on my arms where I was beaten....I felt humi-
liated and dehumanized to the extent that I almost
committed suicide. I couldn’t bear it”[38].
Reported another female inmate:
“Truthfully, each officer has her own problems.
Some are harsh, some don’t accommodate us. To
tell the truth, we were told to say that there are no
problems, but each has their own problems. They
beat and shout at us, so we can’t share a problem–
they are not approachable....They degrade us, shout,
call us names, make reference to the fact that we are
criminals”[31].
In addition to beatings, at one prison, female prisoners
reported sexual humiliation as punishment. Prisoners
reported being stripped naked, smeared with mud, and
placed in the direct sunlight of the prison central court-
yard to be viewed by all female prisoners for an entire
dayaspunishment.Onefemaleinmatedescribedthis
punishment as “aimed at humiliating or insulting our
personality”and asked: “How can they make me strip
naked before younger women who could be my daugh-
ter, without taking to consideration how I would feel as
a woman, as a mother?”[38]
Further forms of sexual humiliation and verbal abuse
exist for female inmates. One inmate reported that as
punishment, the officers may put the inmate into the
center of a circle of the other prisoners at bath time,
where each “showers insults at her, calling her the
names of private parts”[15].
Female prisoners also reported feeling abused by rou-
tine strip searching by officers. Inmates reported that
they were strip searched, both when returning from
court, and at regular intervals in the cells themselves.
Multiple inmates reported the shame involved. “Ifeel
grieved about it”,onesaid,“IevenpraytoGodthatI
can just die. The pain and shame is too tough to bear”
[38]. In one instance, researchers received a report from
a prisoner that a body cavity search for all female
inmates was carried out with a single pair of gloves [13].
Discussion
This study is the first independent research conducted
on issues related to the health and human rights of
female detainees in Zambian prisons. Our findings indi-
cate that both the healthcare available to and the abuse
endured by women in detention in Zambia violate inter-
national human rights law. Women in Zambian prisons
are not provided with healthcare services to address
their specific health needs, and are underserved by the
HIV and TB testing which does exist.
While there has been relatively little research con-
ducted to date addressing the distinct healthcare needs
faced by women in detention worldwide [2,39,40], and
even less in Africa, news accounts suggest major pro-
blems, including: poor conditions and no medical care
for women detained in a Sudanese prison [41]; physical
abuse against women in a Mauritius prison [42]; and
rape and sexual violence against female detainees by
male inmates in the Democratic Republic of the Congo
[43].
Understanding the human rights abuses impacting
female prisoners’health in incarceration facilities is key
to devising appropriate, effective services for this popu-
lation, and may become increasingly important in com-
ing years: Female prison populations have increased in
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both absolute numbers and in proportion to the male
population in some countries recently [44].
Under international human rights law, people in
detention retain their human rights and fundamental
freedoms–aside from such restrictions on their rights as
are required by the fact of incarceration [17,45,46] and
except as necessary for the justifiable segregation or the
maintenance of discipline [17]. States have an obligation
to ensure medical care for prisoners at least equivalent
to that available to the general population [47-49]. The
current lack of access to health care–evidenced by the
lack of facilities in Zambian prisons and the evaluation
of medical needs by untrained and unqualified guards–
falls far below the equivalent standard of available treat-
ment in the community. Further, the Convention on the
Elimination of All Forms of Discrimination against
Women obligates states to ensure to all women–in and
outside of prison–appropriate services for pregnancy,
including adequate nutrition [50].
Respecting female detainees’humanrightsisalso
essential to preventing abuse and ensuring the health of
female detainees. The most fundamental protection for
detainees is the absolute prohibition on torture, inhu-
man or degrading treatment or punishment. In addition
to being a well-established norm of international law by
which Zambia is bound, the prohibition is also reflected
in the Zambian Constitution and in several of the
human rights treaties to which Zambia is a party
[47,48,51,52]. Yet the physical abuse suffered by Zam-
bian female detainees in police and prison custody vio-
late national and international law prohibitions on
torture or cruel, inhuman or degrading treatment or
punishment, as well as having negative consequences for
their health.
There were several limitations to our research.
Women prisoners in only four of 86 prisons nationwide
were interviewed, and the recruitment of prisoners
required cooperation of prison officers. Researchers did
not have access to the one female prison in Zambia, and
so were restricted to interviewing female detainees held
inprimarilymaleprisons.Becausetheprisonswhere
interviews took place were participating in an ongoing
HIV prevention program run by a non-governmental
organization (PRISCCA), and subject to visits by NGO
staff, conditions may have been better than in prisons
not participating in the program. Similarly, the selection
of prisoners by prison officers likely biased the sample
to healthy prisoners not currently in punishment cells,
who were possibly more likely to portray prison staff
and conditions in a positive light.
However, using mixed-method approaches and trian-
gulating information from prisoners with in-depth inter-
views with prison officers and NGO and government
representatives strengthened our confidence in our main
findings. Even if our results suggest more positive condi-
tions than those experienced by a more representative
sample of female Zambian prisoners, the findings iden-
tify serious human rights abuses and failures to provide
healthcare that compel further investigation, monitoring
and response by the Zambian government.
Conclusions
Although women detainees are entitled to protection
under international human rights law and enjoy specific
protections under regional human rights standards, in
Zambia, incarcerated women’s specific health needs are
not being met, and they are underserved by general health
services. There is an urgent need for healthcare services
targeted to female inmates, including prenatal care, to be
expanded, and for general prison health campaigns includ-
ing HIV and TB prevention, testing and treatment to
include women prisoners. Abuses against women both in
police and prison custody which violate their rights and
compromise their health must be eliminated.
Acknowledgements
The authors would like to thank Godfrey Malembeka, Michaela Clayton,
Kathleen Myer, Megan McLemore, Rebecca Shaeffer, Darin Portnoy, Chris
Mumba, Nyaradzo Chari-Imbayago, Kelvin Musonda, Shadreck Lubita,
Rodgers Siyingwa, and George Chikoti for support in data collection and
analysis.
This research was funded by Human Rights Watch and the AIDS and Rights
Alliance for Southern Africa, both independent, non-governmental
organizations, as well as the Bernstein fellowship program at Yale Law
School.
Authors’contributions
KWT and JJA conceived the study. KWT led the field research and KWT and
JJA drafted the manuscript. Both authors read and approved the final
manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 15 October 2010 Accepted: 22 June 2011
Published: 22 June 2011
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Cite this article as: Todrys and Amon: Health and human rights of
women imprisoned in Zambia. BMC International Health and Human
Rights 2011 11:8.
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