later that night
i held an atlas in my lap
ran my fingers across the whole world
where does it hurt?
During the course of writing this chapter, COVID-19 has had an unprecedented global impact, taking the lives of more than 6 million people worldwide. It is critical to understand the specific dire effects the pandemic has had on the health of women and girls. There has been a 148 percent increase in gender-based violence during the quarantine period, increased economic and food insecurity, and lack of access to sexual and reproductive health care (Chosid 2020). Additionally, while women comprise 70 percent of the global health workforce, they hold only 25 percent of senior decision-making roles (van Daalen et al. 2020). Only 3.5 percent of 115 identified COVID-19 expert task forces have gender parity in their membership. Male dominance in global health leadership positions is the symptom of a broken system. These power structures fail to reflect gender, sex, geographic, racial, or socioeconomic equity within and beyond health, and the lack of women and gender-responsive practices in COVID-19 decision-making bodies has ultimately cost lives (van Daalen et al. 2020). Thus the COVID-19 pandemic has highlighted the fact that women across the globe suffer from tremendous health inequities, including those related to unequal power relations, poverty, violence, and decreased access to education (Mark 2020).
The denial of access to health care, combined with the disparities compounded by systemic racism and violence against women, create an overwhelming international health crisis. In order to enact and maintain functional health care systems, radical and systemic change that utilizes gender-responsive and intersectional practices is crucial. Such work requires an intersectional framework to health analysis and intervention, which recognizes the existence of inequities based on gender, race, income, class, sexuality, geography, ability, and more.
This chapter focuses on gender and health within a transnational context. It presents health as a human right and discusses ways the politics of gender, or the ways power and resources are distributed according to gender, help construct health outcomes. Using an intersectional feminist framework and centering marginalized communities, the first part of the chapter seeks to understand health inequities. Later in the chapter, I conceptualize various approaches to health equity and health care that address historical roots of oppression and structures of power. The chapter ends with a focus on disability justice, taking into consideration the context of the present global pandemic.
The World Health Organization (WHO) makes the case for health as a human right, defining it as “a state of complete physical, mental and social well-being and not merely the absence of diseases and infirmity” (1948). Central to this definition is the point that health involves not merely a right to be healthy or to access health care, but also a holistic notion of “well-being” grounded in a wide range of social, cultural, and economic factors that promote conditions in which people can lead healthy lives.
Human rights related to health are embedded in international rights instruments as well as national constitutions all over the world. More than fifty years ago, in 1966, for example, the International Covenant on Economic, Social and Cultural Rights (ICESCR) declared “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” According to the United Nations High Commissioner for Refugees (UNHCR), it specifically called for the reduction of infant mortality and the maintenance of child health; the improvement of environmental and industrial conditions to ensure good health; and the prevention, treatment, and control of common diseases that occur at a constant but relatively low rate (endemic) and those that involve new cases in ways that exceed what might be expected (epidemic) (UNHCR 1966).
In 2000 the UN Committee on Economic, Social and Cultural Rights clarified the right to health to include: (1) availability of “functioning public health and health-care facilities, goods and services, as well as programs” in sufficient quantity; (2) accessibility of health facilities and goods and services for everyone (accessibility implies the idea that no one should be denied access as a result of discrimination, physical disability, lack of economic resources, or lack of access to information); (3) acceptability of health services and facilities in terms of medical ethics that included cultural and gender sensitivity; and (4) ample quality of health services that meet scientific and medical standards.
This report also emphasized the need for timely and appropriate primary health care; access to safe and potable water and adequate sanitation; an adequate supply of safe food, improved nutrition, and housing; healthy occupational and environmental conditions; and access to health-related education and information, including information on sexual and reproductive health. A final section required nations to create national public health plans of action that address the health concerns of the entire population. In this way, the right to health is not to be interpreted as only a right to have health services, but it should also embrace a wide range of socioeconomic factors for healthy living (Gruskin and Tarantola 2005).
The Sustainable Development Goals: Is It Time to Reexamine?
The United Nations General Assembly (2015) agreed upon seventeen Sustainable Development Goals (SDGs), listed below, under the overarching principle of “leaving no one behind.”
Sustainable Development Goals (SDGs)
Goal 1. End poverty in all its forms everywhere.
Goal 2. End hunger, achieve food security and improved nutrition, and promote sustainable agriculture.
Goal 3. Ensure healthy lives and promote well-being for all people at every age.
Goal 4. Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all.
Goal 5. Achieve gender equality and empower all women and girls.
Goal 6. Ensure availability and sustainable management of water and sanitation for all.
Goal 7. Ensure access to affordable, reliable, sustainable, and modern energy for all.
Goal 8. Promote sustained, inclusive, and sustainable economic growth, full and productive employment, and decent work for all.
Goal 9. Build resilient infrastructure, promote inclusive and sustainable industrialization, and foster innovation.
Goal 10. Reduce inequality within and among countries.
Goal 11. Make cities and human settlements inclusive, safe, resilient, and sustainable.
Goal 12. Ensure sustainable consumption and production patterns.
Goal 13. Take urgent action to combat climate change and its impacts.
Goal 14. Conserve and sustainably use the oceans, seas, and marine resources for sustainable development.
Goal 15. Protect, restore, and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, halt and reverse land degradation, and halt biodiversity loss.
Goal 16. Promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build effective, accountable, and inclusive institutions at all levels.
Goal 17. Strengthen the means of implementation and revitalize the global partnership for sustainable development.
Lost in the Desert
by Sarah Baum
When we think of a desert, a dry, desolate place comes to mind. The same thing is true when it comes to food deserts. The US Department of Agriculture defines a food desert as an “area . . . with limited access to affordable and nutritious food, particularly such an area composed of predominantly lower income neighborhoods and communities.” For urban areas to qualify as a region of low access, they must have at least five hundred people and/or at least 33 percent of the census population residing more than one mile from a supermarket; in rural areas the distance is ten miles.We tend to think of food deserts as a US problem, but it’s a global one, affecting people across the globe in both developed and developing countries. Living in a food desert doesn’t just mean limited access to a grocery store, but also limited selection of affordable, healthy options, leaving residents to rely on junk foods, limited variety, and options with low nutritional value.
In Cape Town, South Africa, there is an 81 percent rate of food insecurity; because of the fractured transportation system, people spend so much time commuting that they rely on ready-to-eat foods, which are expensive and unhealthy. Australia also is dealing with the food desert issue. In Western Australia, access to fruits and vegetables is often limited by season, distance, and much higher prices. In some areas, families would need to spend nearly 60 percent of their income to buy healthy food. Food deserts are a growing global problem that is not easily solved, but one to which we must find a solution.
Originally, the core goal of these policies was to set an agenda to reduce global health inequities within the population by enabling access to comprehensive health care and services. Prior to the COVID-19 pandemic, considering these SDGs from a feminist perspective gave rise to both praise and critique. Praise emerged primarily in response to how the SDGs have improved upon or departed from limitations in the 2000 Millennium Development Goals (MDGs). In particular, the SDGs have attempted to not only address gender and women’s rights through a specific goal, but also to incorporate these issues as parameters into several other goals. Furthermore, the creation of SDGs entailed a more equitable and inclusive process than the top-down approach that led to the MDGs. The SDGs are applicable worldwide, allowing individual countries to adapt them as their needs require, whereas the MDGs targeted low-income nations. The SDGs also addressed hierarchies within countries and the inequalities between the Global North and the Global South. Lastly, the SDGs set forth a more comprehensive framework for implementation and outcomes than did the MDGs (Consortium on Gender, Security and Human Rights 2017).
Nevertheless, feminist perspectives also offer criticism of the SDGs. Specifically, these critiques focus on structural issues of the SDGs, noting that the SDGs encourage traditional economic models and fail to address power relations and social structures. These critiques apply to areas in which the SDGs remain silent or undeveloped; for example, the SDGs fail to discuss their impact on nonconforming genders and different sexual orientations, lack a focus on collective action, and are absent of human rights language. Specific critiques address the SDGs themselves; for example, Goal 5 is critiqued for its assumption that greater presence of women in politics will benefit all women, and it falsely equates gender equality with economic equality. Finally, critics points out weaknesses surrounding the implementation of these goals, asking whether the goals are too ambitious and abstract, and whether they will be weakened as a result of adapting to pressures within different countries (Consortium on Gender, Security and Human Rights 2017).
To address these concerns and to reexamine the progress of the SDGs, the United Nations’ High-Level Political Forum convenes annually. Each year, they focus on a specific set of goals and review the implementation progress in certain countries. After the 2017 forum, the Women’s Major Group laid out five critiques of the current progress: they recommended that SDGs be implemented with a human rights approach; a meaningful representation of women should be involved; civil society spaces should be maintained and strengthened through diversity; finances should resource women’s rights groups; and accountability must be taken by all. Until these criticisms are addressed, women’s rights and feminist groups will continue to ensure these areas of improvement or need are brought to the public’s attention (Consortium on Gender, Security and Human Rights 2017). Progress across the SDGs before the pandemic was slow, and of the seventeen SDGs, only two were close to being achieved. But because of the global pandemic, most of these goals are now out of reach, and advocates are calling for a radical shift in SDGs, specifically in relation to gender inequities and violence against women, girls, and other marginalized communities. The impacts of COVID-19 have contributed to a significant rise in domestic violence as well as additional access barriers to sexual and reproductive health care for women. It is estimated that more than 71 million people were pushed into extreme poverty in 2020, and women suffered disproportionately from loss of employment and additional difficulties accessing food, shelter, child care, education, health care, and disaster relief services (United Nations Department of Economic and Social Affairs 2020).
Although health has been constituted as a human right, it must also be understood in the context of gender relations and other differences among women. A recent article from the Lancet Commission on Gender and Health argued that despite the body of knowledge regarding gender and health, for decades consideration of gender in global health has been neglected, with the authors stating that “Gender is everywhere in global health discourse and promises, but nowhere in action or accountability plans,” meaning the world’s community is not on track to meet its Sustainable Development Goals (Hawkes et al. 2020, 528).
We must consider the links among women, gender, and health beyond increased risk factors, and look at historical structures and systems that create health inequities. An intersectional approach to health and health research has gained widespread interest and momentum in recent years. The term intersectionality was coined by Kimberlé Crenshaw in 1989 and is rooted in Black feminist theory and scholarship. It has been widely recognized as an approach to analyze the systems of power and oppression that produce and maintain health inequities and other kinds of inequities. Further, “intersectionality moves beyond examining individual factors such as biology, socioeconomic status, sex, gender, and race. Instead, it focuses on the relationships and interactions between such factors, and across multiple levels of society, to determine how health is shaped across population groups and geographical contexts” (Kapilashrami and Hankivsky 2018, 2589). Understanding global health inequities requires an intersectional approach, and gender cannot be considered in isolation without acknowledging the complex ways that power operates to create inequities in health and other layers of marginalization and discrimination.
Globalization, Neoliberalism, and Health Inequities
Globalization and neoliberalism play a major role in shaping political and economic relationships across the world and are a driving force for health inequities. Structural adjustment policies, or SAPs, are imposed by global multilateral organizations such as the International Monetary Fund (IMF) and the World Bank as a condition of international lending, thus furthering neoliberalism. SAPs require indebted countries to reduce levels of public expenditure in order to assist the repayment of international debt and/or readjust spending patterns in line with perceived needs of a globalizing world economy. These policies directly influence health outcomes as a result of what is sometimes called a “hollowing out” of individual states that reduces the provision of health care and other services (Reinsberg et al. 2019). While these practices may increase gross national product (GNP), measures in these countries destroy national infrastructure and bring hardship to individual citizens, especially women and minoritized communities. In high-income countries, such conditions mainly affect low-income and communities of Black, Indigenous, and Other People of Color (BIPOC). By expanding markets for transnational corporations, economic globalization tends to drive out rural production in industrializing countries and instead provides work with low pay, little job security, shelter, or benefits, and potential health hazards. The end result has been loss of livelihood and ancestral farms along with increased health problems.
One example of the toll these global health inequities have disproportionately had on certain populations can be seen in the marginalized workforces of both the majority and minority worlds. Economic globalization has created transnational factory production as a result of the relocation of labor-intensive factories (such as garment and some electronics manufacturing) to lower-wage areas in Asia and Latin America. In these zones, companies are often exempt from health, safety, and environmental regulations that affect the health and well-being of workers. Often, young women are sought as cheap, easily controlled labor and treated as disposable with no or few concerns about long-term health consequences. For example, since the passage of the North American Free Trade Agreement (NAFTA) in 1994, Mexico is home to more than three thousand maquiladoras (assembly sweatshops producing for export) that employ mostly female Mexican workers. Maquiladoras are owned by US, Japanese, and European companies, and some could be considered “sweatshops,” with young women working for as little as 50¢ an hour, for up to ten hours a day, six days a week. These women workers have no job security or benefits and are often subject to sexual harassment and unsafe working conditions (Demeter 2019). The high number of maquiladoras in Ciudad Juárez have made the state of Chihuahua the epicenter of the pandemic. But with direct reports of more than two hundred deaths of maquiladoras workers alone, only 50 of the city’s 320 factories closed, with workers’ rights violated and their lives put at risk repeatedly since the start of the pandemic (López 2020).
Incarcerated Women of Color Are Especially Vulnerable to COVID-19
by Cristina Rodriguez
Women are always at high risk of disease (e.g., HIV/AIDS, tuberculosis, and hepatitis) while incarcerated in crowded prisons. The COVID-19 pandemic is an extreme example. In many facilities, there is a shortage of PPE (personal protective equipment), such as masks, and air may be recirculated, spreading the virus. Some of these facilities have unclean/unsanitary conditions in general as well as inadequate medical care.
Women may be forced into rehabilitation programs to comply with probation requirements and are therefore put in difficult situations in order to better themselves and reunite with their families. For example, Elizabeth Lozano from California wrote Governor Gavin Newsom a letter expressing her concerns about being forced to attend a drug reentry program after being diagnosed with COVID-19 the week of July 15, 2020.
Women of color are disproportionately affected by such poor conditions. They already face higher rates of incarceration than white women, they may be economically and educationally disadvantaged, and they may have mental health issues, all of which make them more vulnerable to disease. As the COVID-19 crisis intensifies, women will continue to suffer the consequences from a flawed justice system that puts them in vulnerable positions.
India is another place where marginalized groups and workforces have suffered disproportionately from COVID-19. There, migrants and urban slum dwellers have faced multiple challenges brought about by the pandemic. India was first locked down by government order in March 2020. Because these lockdown restrictions severely affected the economy, they were gradually relaxed and lifted over the following months despite infections continuing to rise. As of April 2021, India was third in the world in terms of the number of COVID-19 cases, with more than 10 million people reported infected; the actual number of infections was likely significantly higher owing to limitations in testing and tracing (Raju, Dutta, and Ayeb-Karlsson 2021).
In considering the Indian subpopulations hit hardest by COVID-19, 95 percent of reported infections were localized to urban spaces (e.g., Chennai, Delhi, Kolkata, Mumbai), and one in six urban Indians resides in an area characterized by high poverty, with several factors that increase the risk of COVID-19, such as high population density, weak health services, and informal income structures. Furthermore, 35 percent of those living in such areas have no access to clean water or sanitation, and these areas are already prone to high rates of infectious diseases such as pneumonia, diarrhea, and tuberculosis; such comorbidities present a grim outlook for people living there to successfully fight off COVID-19. Also contributing to this poor outlook is the fact that social inequality, poverty, and mental health issues decrease one’s ability to respond to stress (Raju, Dutta, and Ayeb-Karlsson 2021).
Migrants in India have also been especially hard-hit by the pandemic. Migrant workers typically reside in informal settlements built around existing factories or industrial areas. Here, they lack access to affordable health care and face heightened health and safety risks. The travel and lockdown restrictions often left these migrant workers unable to leave, but without work, they became stranded, impoverished, and without sustenance. These groups already faced high levels of discrimination and stigmatization before the pandemic, and the current global health crisis has exacerbated these issues (Raju, Dutta, and Ayeb-Karlsson 2021).
Gender disparities and food insecurities have also worsened in impoverished and migrant communities. Women have been forced to perform more unpaid work, and often people are forced to choose between starving or finding food and potentially increasing their risk of COVID-19. In migrant communities, pregnant women have died without access to maternal health services. Women have suffered from increases in domestic abuse during the pandemic, and with many women losing their employment and source of income, they become more susceptible to this abuse, creating a vicious cycle (Raju, Dutta, and Ayeb-Karlsson 2021).
Racial Inequity in COVID-19
by Christiana Huss
Inequities in health care are by no means limited to the Majority World. COVID-19 has highlighted the inequities inherent in the US health care system. In Michigan in particular, this divide has been underscored during the pandemic: the state is made up of 13 percent Black people, yet Black people accounted for more than 40 percent of COVID-19 deaths early on. In attempting to understand this pattern, the particularly tragic story of one woman is notable. Dr. Susan Moore studied medicine at the University of Michigan and graduated in 2002. In 2020, during the height of the pandemic, Dr. Moore reported to her hospital colleagues the symptoms and pain she was experiencing, advocating repeatedly for proper care. Nevertheless, her pleas were repeatedly dismissed. Less than a week before Christmas, Dr. Moore died of COVID-19 (Wixson 2021).
Realizing how tragically easy it was for a highly educated medical professional—who happened to be a Black woman—to be so easily disregarded stresses how profoundly ingrained systemic racism is in the US health care system. The University of Michigan is working to rectify this imbalance with the Antiracism Oversight Committee and university-wide plans to address diversity, yet Moore’s story exposes this devastating reality for people of color in the United States. How will the rest of the states and our society holistically address this inequity?
Health inequities also exist as a result of the environments our systems create and impose upon marginalized groups. Globalization has precipitated environmental degradation and has endangered the health of agricultural workers and families living in communities through exposures to toxic herbicides and pesticides. Paul Webster in his article, “Canadian Petrochemical Plants and Gender Imbalances,” discusses the health problems among the North American Chippewa on Canada’s Aamjiwnaang Reserve, where petrochemical plants pollute the environment. The tribe’s complaints were ignored until a recent study found a significant reduction of male births caused by the toxins. This was not the first time toxins have posed serious environmental and health effects to this region, though earlier events have been grossly understudied; oil workers in the 1970s faced high levels of exposure to asbestos, and in 1985, more than thirty toxins—including arsenic, mercury, and polychlorinated biphenyls (PCBs)—coagulated at the bottom of the St. Clair River after a chemical dump. Air quality is also highly jeopardized by emissions from nearby refineries, some of which are located across the street from Aboriginal homes and a kindergarten (Webster 2006).
These problems gained greater attention after a medical intern at the University of Ottawa noted declines in the male birth rate during the 1990s into the 2000s. From 1999 to 2003, only 46 of 132 babies born were male; historically, the ratio of male:female births was 105:100. Though Webster (2006) reports that “the link between pollutants and reproductive effects remains speculative,” indication of such a link has been widely shown in animal studies, as various species exposed to the chemicals in this area have displayed significant reproductive abnormalities such as embryonic mortality and interference of hormone production. Nevertheless, a comprehensive study of the issues faced by these marginalized people remained out of reach without the monetary support of the Canadian government (Webster 2006).
Economic globalization has affected marginalized groups in ways beyond these environmental detriments. It has facilitated wars worldwide that disproportionately affect women and other underrepresented populations’ health. Women face displacement and destruction caused by conflict, and they are often targets of gender-based violence. Of the more than 79 million refugees and internally displaced persons as a result of armed conflict or natural disasters, 52 percent were women and more than 40 percent were children in 2019 (UNHCR 2020). Wars often limit access to clean drinking water, food, adequate shelter, sanitary facilities, and health services, resulting in higher risk of epidemics and nutritional problems. Armed conflict threatens women’s rights, including reproductive rights and health, and can exacerbate culturally rooted gender inequalities. Women refugees also often face unwanted and unplanned pregnancies owing to sexual violence and a lack of access to contraceptive services (Kapilashrami and Hankivsky 2018). Access to sufficient nutrition and health care during these pregnancies is often lacking or absent. Forced pregnancies (often as means of dishonor or furthering the nationality of the perpetrator), sterilization, and trafficking are also common (International Committee of the Red Cross 2004). The lack of sanitary supplies for menstruation can impede the mobility of women and girls and may cause them to experience discomfort, shame, and isolation for several days each month. Pregnant women and nursing mothers may also find that there is limited care available. While fleeing or during early settlement, or because of delays and perilous conditions required to reach a hospital even when this is an option, women may have to give birth in conditions hazardous both to them and their children (International Committee of the Red Cross 2004).
Such conditions often result in higher maternal mortality rates. A study of Afghan refugees, for example, showed that 41 percent of women’s deaths were from maternal causes, exceeding any other cause (Bartlett et al. 2005). Comparing women of reproductive age, those living near areas of high conflict have a mortality rate three times higher than those in peaceful environments, and the number of women living near areas of high conflict has increased significantly in recent years, from 185 million in 2000 to 265 million in 2017 (Singh et al. 2021). Rape, sexual exploitation, and sex for survival during war lead to early pregnancies and put women at greater risk of HIV/AIDS, sexually transmitted infections (STIs), an increase in (often unsafe) abortions, psychological harm, and immediate and serious physical injuries, such as infertility, obstetric fistulas, and vaginal bleeding.
The negative effects of war and displacement on mental health also disproportionately affect women, likely as a result of gender-based violence. Depression and anxiety disorders among those who have been displaced are estimated to be two to four times higher than those in peaceful settings. Children, too, have significantly higher rates of mental health problems in the face of war and displacement, likely attributable to increased domestic and sexual violence, and structural breakdown in the familial unit (Singh et al. 2021).
War and Birth Defects in Iraq
by Maysa Shakibnia
War and its repercussions are another way that systems of violence affect communities. In Iraq, unfortunately, babies and children bear the brunt of reproductive violence, as birth defects are a visible embodiment of the enduring toxic legacy of war for future generations and the environment (Rubaii 2020). It is not uncommon for babies in Fallujah, Iraq, to be born with hydrocephaly, cleft palates, tumors, elongated heads, overgrown limbs, short limbs, and malformed ears, noses, and spines. Case reports of babies who are “incompatible with life” or “stillborn” are also not unusual.
Dr. Samira Alaani, a pediatrician at Fallujah General Hospital, first began noticing the wide range of uncommon birth defects among infants just after the US occupation in 2003 (Rubaii 2020). The birth defects were strange in that they were numerous, with 144 babies being born with deformities for every 1,000 live births. These alarming rates exceed those of Hiroshima and emphasize the connections of militarism, public health, global inequities, and environmental racism (Rubaii 2020). The bodies of these children are a consequence of the toxic legacy of war in Iraq, as it has been suffering under decades of war, bombings, burn pits (military-based waste disposal), sanctions, and other military interventions that cause cascades of environmental degradation as well as destroy necessary health care and public systems (Rubaii 2020).
While human-made environmental effects tend to disproportionately affect marginalized groups, natural environmental changes and disasters also severely impact these groups. In terms of climate change, the health consequences (including death) of tsunamis, hurricanes, and tornadoes are tremendous for all involved. The 2004 tsunami in the Indian Ocean highlights the disproportionate harms women face in disaster situations. According to Oxfam Briefing Note (2005), in the four villages of the Indonesian Aceh Besar district, 189 of the 676 survivors were female. In four villages in Indonesia’s North Aceh district, women accounted for more than three-quarters of the deaths, and in Cuddalore, India, almost three times as many women were killed as men. In fact, in one entire village, the only people to die were women (Oxfam Briefing Note 2005). From the time disaster strikes, women become more susceptible to violence that compromises their physical and emotional health. For example, after the Indian Ocean tsunami, some women who were pulled out of the water alive were assaulted as “payment” for being saved (Oxfam Briefing Note 2005).
Such environmental health effects again came into focus this past year. In 2020 the world suffered from both the repercussions of COVID-19 and an onslaught of climate crises, including wildfires, rising sea levels, hurricanes, and droughts. As has been observed historically, these natural disasters have disproportionately affected minority groups. Communities of color have been hit the hardest by both the pandemic and climate crises. Anti-Asian hate crimes have spiked in the United States, as have discriminatory actions toward Muslims. Racial minorities, often making up a large proportion of farmworkers, domestic servers, and food preparers, commonly lose their jobs as a result of climate change. Exacerbating these disparities is the fact that there are significant gender imbalances in positions of decision-making regarding the pandemic and climate. Class lines have also been highlighted. Those with greater wealth have been able to shield themselves from many of the negative effects of the pandemic and environmental changes (e.g., being able to travel by private jet, having greater access to health care and financial resources) (Sultana 2021).
Community Health Workers: Providing Most of the World’s Health Care
by Shannon Garvin
In rural communities across the globe, community health workers (CHWs) are the backbone of medical care. CHWs are defined as “any health worker carrying out functions related to health care delivery; trained in some way in the context of the intervention; and having no formal professional or paraprofessional certificated or degreed tertiary education.”
The United Nations (UN) estimates nearly a million people work as CHWs across sub-Saharan Africa. In communities without hospitals, clinics, or even a local nurse, CHWs help with childbirth, family planning, diagnosing malaria, bandaging wounds, immunizations, and other vital health services. CHWs go door to door in their local villages—they are generally lay members of the same communities they are seeking to serve.
The value of their services is evident: Muyingo Prossie, a community health worker in Uganda, says, “Ever since I became a community health worker in my community, no woman or child has died during delivery.” The COVID-19 pandemic has introduced additional challenges; shortages of personal protective equipment (PPE) like gloves, and the need to change between each patient, means services may be slower. Mariam Traoré of Mali says, “I typically visit up to 32 homes a day. However, when there are many children requiring my attention, I may not be able to visit as many homes.”
CHWs also offer the majority of health services across Southeast Asia, and in Russia, CHWs are being trained to administer first aid in remote villages where there are no medical professionals or clinics have been closed for lack of funding. The UN notes this can be a sustainable path for women to gain employment as they work in their communities.
For more information, check out the following report, which includes information about CHW programs from Afghanistan to Zimbabwe.
The year 2020 also laid bare the state of reality for different groups of women. As mentioned above, white upper-class women were able to avoid many pitfalls of the virus, while this period simultaneously “heightened marginalizations for others, whereby socially reproductive labor burdens on migrant women and working-class women allowed for greater ‘success’ for others based on whiteness and class” (Sultana 2021). Traversing the lines of class and race, all women faced reduced access to reproductive and preventative medical care. Furthermore, climate crises increase the workload for many women who shoulder daily burdens of water provision in the Global South. In flood-prone and drought-ridden areas, this task became onerous when water was needed more than ever for handwashing and sanitation measures necessary to combat COVID-19. When women were not able to carry out this critical role, increases in gender-based domestic violence rose (Sultana 2021).
In terms of both wars and natural disasters, alongside the health hazards of living in refugee and displacement camps in crowded conditions without adequate sanitation levels and with limited resources, patriarchal practices (such as serving a greater portion of nutritious foods to males and avoiding medical attention for women exhibiting signs of malnutrition) can result in women’s decreased immunity and increased disease. Female children, both inside and outside of refugee camps, who have lost one or both parents in conflicts or disasters may be forced into child marriage or trafficking for economic and survival reasons fueled by patriarchy. Other than child marriage and human trafficking, wars, natural disasters, and global crises also lead to increased gender-biased sex selection and intimate partner violence (IPV). The humanitarian crisis as a result of COVID-19 has proven no different. A recent report by the United Nations Population Fund (UNFPA) shows that COVID-19 has undermined critical efforts to end child marriage and gender-based violence as well as access to education and reproductive health services for women and girls (UNFPA 2020a).
Economic globalization has led to a widened gap and increased inequality around the world, placing a greater burden on women and children. Today, 736 million people are living on less than $2 a day, especially in sub-Saharan Africa and southern Asia. During the past twenty years, for example, despite several decades of “development,” poverty levels for rural women in forty-one countries of the Majority World have increased by almost a fifth. Female poverty affects women’s roles in maintaining food security for families and households and therefore affects community health (United Nations Department of Economic and Social Affairs 2020). Globally, one in nine people is hungry or undernourished. Data show that nearly 690 million people, or 8.9 percent of the world population, are hungry—up by 10 million people in one year and by nearly 60 million in five years. The majority of the world’s undernourished—381 million—are still found in Asia. According to the Food and Agricultural Organization (FAO), more than 250 million live in Africa, where the number of undernourished people is growing faster than in any other region of the world (FAO 2020). The majority of undernourished people in Africa are found in the sub-Saharan subregion, which shows an increase of about 32 million undernourished people since 2015. Hunger has been on the rise throughout sub-Saharan Africa since 2014, though the increase has been especially significant in the eastern and the western subregions, and women and children are especially affected (FAO 2020).
As already mentioned, women and girls have access to fewer household resources like food, leading to higher malnutrition and mortality rates. Because of their lower social and economic status as well as their physiological needs (such as childbirth and lactation), women are often more vulnerable to nutritional problems. As the price of food has increased around the world, women face higher risks of malnutrition because they usually eat last, and less, after providing for their children and family. Food security and nutrition are closely connected. Since households in the Majority World spend an average of 70 percent of their incomes on food (compared to the 15 to 18 percent spent in high-income countries), increases in food prices cause them to sink further into poverty. Poor female nutrition early in life reduces learning potential, increases reproductive and maternal health risks, and lowers productivity. Frequent pregnancies and heavy workloads, combined with poor diets and frequent infections, can severely weaken a woman’s health. In South and Southeast Asia, 45 to 60 percent of reproductive-age women are underweight, and up to 80 percent of pregnant women are iron deficient.
Period Poverty and the Tampon Tax
by Shannon Garvin
Period poverty and tampon tax have become international catchphrases as activists, government officials, corporations, and brave individuals have worked to break millennia-old taboos against speaking about menstruation and the need for girls and women to have safe access to supplies. In many parts of the world, women still use rags when they menstruate and because of local religious rules are not allowed to wash and dry their rags outdoors. Rags are hidden under beds and bacteria grow quickly, leading to illness.
Period poverty describes the economic reality that most women cannot afford basic hygiene supplies when they menstruate. As part of this, the tampon tax (which refers to the fact that in many places menstrual products are subject to sales taxes rather than being exempt, as are other essential supplies) has been recalled in several countries and thirteen states in the United States. Kenya ended its tax in 2004 and South Africa in 2019.
In addition to adding menstrual supplies to tax-exempt medical lists, period poverty has seen a number of groups partnering to bring free supplies to schools and communities. While rewashable supplies are more eco-friendly, in countries without water or with religious taboos, women need disposable supplies to menstruate safely. In Africa, one in ten girls still misses school on days she is having her period. In some countries, girls are simply withdrawn from school when they start menstruating. Indian inventor of a sanitary pad-making machine Arunachalam Muruganantham is featured in Pad Man, a film available on Netflix. Because this topic is so urgent and affects half of the world’s population, we invite you to further explore locations and topics of interest. Follow the links to learn more.
All these factors contribute to women’s diminished ability to gain access to other assets later in life and undermine attempts to eliminate gender inequalities (FAO 2008, 2020). In addition, malnutrition is perpetuated from one generation to the next, as up to 20 million children are born annually with low birth weight as a result of maternal malnourishment. Low-birth-weight babies are four times more likely to die in the first week of life from infections such as diarrhea and face a tenfold higher risk of dying during the first month of life. Those who survive are more likely to remain malnourished throughout childhood and face cognitive difficulties that impair their ability to learn (FAO 2020). In these ways, investment in women’s nutrition improves not only household nutrition generally but also overall human capacity, given women’s key roles in maintaining family welfare.
Why Do Women Still Die Giving Birth?
The disparities women face do not merely threaten the health or educational prospects of them and their children; their very survival is threatened. Complications related to pregnancy and childbirth are among the leading causes of death for women of reproductive age in many parts of the Majority World. The maternal mortality ratio (MMR), or number of maternal deaths per 100,000 live births, is an approximation of the risk of death of women for reasons related to pregnancy and childbirth. According to the most recent data, around 303,000 girls and women die every year—830 every day—from preventable causes related to pregnancy and childbirth. Death is not the only tragic consequence of complications associated with reproductive health, since nonfatal complications can also have serious effects. For every woman who dies, an estimated 20 or 30 encounter injuries, infections, or disabilities that have painful and long-lasting effects on a woman’s quality of life.
These high maternal mortality rates draw attention to the vast disparities in reproductive health status as a result of poverty, conflict, natural disasters, displacement, and inadequate and poor-quality services that contribute to these high numbers. Sub-Saharan Africa and southern Asia accounted for approximately 88 percent of the estimated global maternal deaths in 2017. Sub-Saharan Africa alone accounted for roughly two-thirds (196,000) of maternal deaths, while southern Asia accounted for nearly one-fifth (58,000) (UNFPA 2019).
Nevertheless, progress has been made in maternal health, and the maternal mortality ratio fell by 38 percent between 2000 and 2017, from 342 deaths to 211 deaths per 100,000 live births worldwide. On average, the global maternal mortality ratio declined by 2.9 percent each year over this period. Still, this is less than half of the 6.4 percent annual rate needed to achieve the global target of 70 maternal deaths per 100,000 live births by 2030. Afghanistan has one of the highest maternal mortality rates in the world, according to United Nations data. There, 638 women die per 100,000 live births, and fewer than 60 percent of births are overseen by skilled health professionals. The causes of maternal death are consistent around the world. Some 80 percent are due to direct obstetric complications: hemorrhage, sepsis, complications of abortion, preeclampsia and eclampsia, and prolonged/obstructed labor. About one-fifth of deaths have indirect causes: generally, existing medical conditions that are aggravated by pregnancy or delivery. These include anemia, malaria, hepatitis, and HIV/AIDS (UNFPA 2019).
Women’s Health Care and Childbirth in Afghanistan
by Christiana Huss
In Afghanistan, 638 of every 100,000 live births result in the mother’s death—one of the highest maternal mortality rates worldwide. Several variables contribute to this statistic, including inaccessibility to health services, poverty, and a low rate of skilled health professionals overseeing births. In response to these deficiencies, Afghanistan’s community midwifery program is supported by the Canadian Government and the United Nations Fund for Population Activities (UNFPA); the trained midwives that graduate from this program establish family health houses to provide health care to rural and remote areas of the country (UNFPA 2020b).
The value and skill of these midwives cannot be understated. Shirin, a graduate who manages a family health house in Usho Golaka, has provided critical, life-saving medical care to hundreds of women in her village. When one of her patients became pregnant with her seventh child, Shirin advised the patient to seek medical care at the provincial hospital because of the baby’s breech position. Nevertheless, it was Shirin whom Fatima’s family called upon in the middle of the night as Fatima began labor. Though this delivery was beyond the scope of Shirin’s training and education, she had no other option but to carry it out; Fatima’s family could not afford to travel to the hospital. Shirin called a gynecologist at the provincial hospital and helped deliver the baby with no more than oral instructions. After less than two hours, Shirin successfully helped Fatima deliver a healthy baby boy (UNFPA 2020).
Although this experience was undoubtedly stressful, Shirin walked away from it with a sense of pride. The implications of this account are both hopeful and indicative of the reality that still disproportionately affects women worldwide; adequate medical training, services, and accessibility are essential to decrease the mortality rates facing pregnant mothers in certain countries.
A steady decline has also been observed worldwide in the adolescent birth rate. It fell from 48 births annually per 1,000 women aged 15 to 19 years in 2010 to 45 in 2015 and 41 in 2020. Contributing factors include efforts to promote healthy reproductive and sexual behavior among adolescents, a reduction in child marriage, and increased access to modern contraception. Yet stark disparities persist across regions: in sub-Saharan Africa, the adolescent birth rate remains at 101 births annually per 1,000 women.
The Global Gag Rule
In seeking to understand why these disparities still exist and so profoundly affect marginalized groups, it is imperative to realize the impact that US foreign policy has had and continues to have on a global scale, particularly on women. The federal Mexico City Policy of 1984 prohibits all foreign nongovernmental organizations that received US international family planning assistance from utilizing their own non-US-provided funds to provide, counsel, or refer abortion services as a method of family planning (Mavodza, Goldman, and Cooper 2019). These strict restrictions became known as the global gag rule (GGR) owing to their inhibitive and silencing effect on any sort of abortion advocacy. Until 2017, these restrictions had only been limited to family planning; however, a presidential memorandum expanded the gag rule to almost all $8.8 billion in global health foreign assistance provided by the United States. Studies have concluded that the GGR does not decrease rates of abortion, and its implementation has been associated with consistently poor impacts of health systems’ functions and outcomes on a global scale (Mavodza, Goldman, and Cooper 2019). The gag rule limits women’s access to family planning worldwide by closing health clinics that provided a range of reproductive health services as well as HIV testing and counseling. Although the Biden administration rescinded the GGR in 2021, enacting the Global HERact Bill would prevent future presidents from unilaterally reinstating the global gag rule via executive action and end the policy’s intermittent use (Sadinsky and Ahmed 2021).
US Women in Contraceptive Deserts
by Sophie Brodish
Within the United States, more than 19 million women of reproductive age are living in contraceptive deserts. Despite the increased development of modern contraception methods, limitations in practice are still found. As of 2016, nearly half of the pregnancies within the United States were unintended, even with North America having the highest male sterilization rate in the world.
Contraceptive deserts are locations where the quantity of health centers is inadequate to meet the needs for the population of women eligible for publicly funded contraception. In order for a county to not be considered a contraceptive desert, there must be one available health center per 1,000 women of the population. Around 1.5 million women in these contraceptive deserts live in counties that lack any form of health center, requiring them to travel multiple hours while they must take off time from work or pay for childcare services in order to be able to receive the care they need.
There are numerous other barriers that can impede a person’s access even within existing clinics across the country. Unavailability of same-gender providers, cost, environment, transportation services, same-day service, and other factors can stand in the way. Environment pertains directly to the treatment of individuals when they seek care at a health clinic. Trans men, trans women, nonbinary folks, and others that the gender binary does not include face an increased difficulty in the number of health centers available to them owing to discrimination.
The primary populations affected by contraceptive deserts are low-income communities and the BIPOC (Black, Indigenous, People of Color) communities. The Title X Family Planning Program was introduced in 1970 as a mode of providing reproductive health services and family planning for low-income communities. In 2019, however, under the Trump administration, a Title X gag rule was implemented, putting affordable care even further out of reach for many, predominantly transgender people and Black women. In October 2021 the Biden administration repealed the rule, bringing hope to the hundreds of thousands across the United States who need affordable and accessible reproductive health services.
Women Should Be Able to Live without Fear of Breast Cancer
Breast cancer is the most common cause of cancer-related death among women around the globe. According to World Health Organization (WHO) statistics from 2020, about 2.3 million women were diagnosed with breast cancer in 2020, resulting in an estimated 685,000 deaths. Breast cancer incidence and rates vary considerably by region. Rates are highest in higher-income Australia, North America, and northern and western Europe, and lowest in the low- and middle-income countries of Asia and Africa. Intermediate levels are reported in Eastern Europe. Five-year survival rates vary significantly based on country: for example, it is more than 90 percent in high-income countries versus 66 percent in India and 40 percent in South Africa. Breast cancer has now surpassed lung cancer as the world’s mostly commonly diagnosed cancer, and it is responsible for one in six of all cancer deaths among women (WHO 2021).
While age is an important factor affecting breast cancer risk, biological risk is also increased by inheritance of genetic mutations (BRCA1, BRCA2, PALB-2), a personal or family history of breast cancer, high breast tissue density (a mammographic measure of the amount of glandular tissue relative to fatty tissue in the breast), and high-dose radiation to the chest as a result of medical procedures. According to WHO (2021), almost half of breast cancers develop in women who have no identifiable breast cancer risk factor other than sex (female) and age (over 40 years). Other factors that increase the risk of breast cancer include increasing age, weight, excessive use of alcohol, reproductive history (age that menstrual periods began and age at first pregnancy), tobacco use, and postmenopausal hormone therapy.
Cigarette Smoke Continues to Cloud Our Health
by Shannon Garvin
Despite all we know about the long-term effects of smoking, people still pick up cigarettes every day. In that process, they also expose others to secondhand smoke and its negative health effects.
While tobacco use is not banned outright, it is considered “wrong” by some religions such as Islam and Christianity. In the United States, tobacco is no longer allowed to advertise as an appealing product. All cigarettes carry warning labels, and the law sets minimum age requirements for purchase. Around the world, however, smoking is still common in most countries. In 2008, the World Health Organization (WHO) put forth a tobacco treaty. In it, countries have agreed to specific measures much like those in the United States, where taxes discourage purchase, age limits are set, and advertising is eliminated.
Tobacco companies that have lost market share in the United States have switched to aggressive marketing internationally. Asia in particular has long been a market for promoting smoking. The European Union is following the US lead in decreasing smoking, but areas such as Africa and Oceania offer opportunities to grow markets of new smokers. In Vanuatu, for example, more than 60 percent of men smoke, but less than 20 percent of women do. Slim cigarettes are marketed to women and children to increase revenue for companies. The death rates in places like the island nations of Oceania reflect the success of these efforts. One-third of men and a quarter of women die from noncommunicable diseases such as heart attacks, diabetes, and other diseases related to smoking and obesity. In homes where the men smoke, 22 percent of the monthly household income is spent on tobacco products instead of food and education.
In high-resource countries, guidelines outlining best approaches to early detection, diagnosis, and treatment of breast cancer have resulted in increased cancer survival rates. Even so, women of color in the United States are more likely than white women to be diagnosed at an advanced stage of the disease and have higher death rates. For example, Black women have a lower incidence rate but a higher mortality rate of breast cancer compared with their white counterparts. Black women have the highest breast cancer death rates of all racial and ethnic groups and a 41 percent higher rate of breast cancer death than white women. These breast cancer disparities mainly stem from institutional racism, racial segregation, discrimination, socioeconomic factors, and reduced access to resources and care such as inadequate screening, inadequate treatment, and lack of access to treatment (Coughlin 2019; Yedjou et al. 2019).
On the global scale, the overall five-year survival rates for Australia, Canada, northern Europe, the United Kingdom, and western Europe is estimated to be higher than 85 percent. Five-year survival rates are much lower in low- and middle-income countries like Algeria (38.8 percent), Brazil (58.4 percent), and South Africa (53 percent), mostly as a result of late-stage diagnoses that lead to higher death rates when accompanied by limited treatment capacities. Many low- and middle-income countries have less than 5 percent of the resources required for adequate cancer control, and according to WHO (2021), more than 80 percent of cancer patients in these countries will be incurable at the time of diagnosis. Alongside insufficient resources, barriers to improving cancer care arise from lack of public knowledge and awareness, lack of efficient screening guidelines, and lack of effective measures for early diagnosis and treatment by the government and the organizing health care facilities (WHO 2021).
Medical Racism: A Case in Point
by Charissa V. Jones
In August 2020, Dr. Asia Muhammad said, “there’s absolutely no reason why any Black person should trust the medical institution.” To understand this statement, we need to look at the historical lack of access to health care among Black, Indigenous, and other People of Color (BIPOC). Medical racism, also called medical apartheid, is the systemic use of racism against BIPOC within the medical system. It is the reason people say racism is a public health issue. Medical mistrust is justified by the centuries of abuse, mistreatment, and neglect that have killed communities of BIPOC.
It has been said that doctors are to Black women what police are to Black men. A case in point is the experience of well-known athlete Serena Williams during the birth of her daughter, Alexis. Even her wealth and fame didn’t afford her the luxury of being heard. The day after she underwent a cesarean section, she explained her history of pulmonary embolisms and shortness of breath, requesting a computed tomography (CT) scan and a heparin drip. Instead of listening and doing as she requested, her nurse assumed the medication she was receiving was the problem, and her doctor ordered an ultrasound instead. When the ultrasound didn’t reveal anything, she was finally granted a CT scan, revealing several small blood clots in her lungs. Williams’s birth experience highlights a recurring theme of Black women (and BIPOC in general) being devalued and disrespected by the medical field. It illustrates that bias shapes how medical professionals perceive and treat their patients.
A Transnational Feminist Approach to Reproductive Justice
Women across the globe suffer adversely from institutional systems, both medical and societal, that are not designed with their best interests in mind. Another realm that disproportionately affects women, some more than others, is that of reproductive rights. It was in 1994 that the United Nations International Conference on Population and Development (UN ICPD), held in Cairo, eventually articulated the concept of reproductive rights in a clear statement in its program of action. Three rights in particular were identified: “the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents” (UN ICPD 2014 , 58).
The question is whether these ambitious goals are within reach in most parts of the world where there is no universal health care and various governmental policies and agendas limit and control women’s access to reproductive rights. Thus the idea of choice and such framing of the reproductive rights movement has come under criticism by social justice activists as mainly fitting the needs and experiences of privileged women in western countries with access to health care. For example, in the United States, pregnancy-related death for Black women is more than three times higher than that of white women, implicating the devastating impacts of racism in access to high-quality health care and health care delivery (Planned Parenthood 2019).
Anti-Abortion Bill Disguised as “Women’s Protection”
by Kelsey Limnell
Senator Eduardo Girão, of Brazil’s “We Can” (Podemos) Party, introduced PL 5435/2020 in December 2020. This bill, known as the “Statute of the Pregnant Woman,” was said to protect women who become pregnant as the result of rape, while actually restricting their legal rights to abortion (already strictly limited), coercing them to continue with unwanted pregnancies, and giving the men who raped them the status of parents.
Girão claimed that the bill “would be an advance in the ‘humanitarian point of view’ by protecting pregnant women and holding men accountable.” But local feminists say it put on a facade of activism, and instead of working to aid in proper women’s rights and reproductive safety, it took the form of a “rape subsidy.”
The bill prompts the creation of a fund to financially support survivors of rape—but only if the woman proceeds with the pregnancy. Unfortunately, the bill doesn’t identify a source for the funding or specify how long it will last, and it excludes women who have financial resources.
In addition, the proposal includes a requirement that women in all contexts must “provide information to the father about the child,” even if that “father” was their abuser—forcing women to stay in contact with the men who raped them. Finally, the bill would prohibit harm to the fetus starting from conception, by “act or decision of any of its parents,” so that not only would abortion be illegal, but pregnant women might avoid other needed medical treatments, such as chemotherapy.
PL 5435/2020 would ignore the fundamentals of women’s rights and instead create a situation where women are not only at risk for lack of proper health care but also face further mental and physical dangers in keeping in contact with the men who abused them.
Feminist and anthropologist Debora Diniz summed it up by stating, “Criminal laws are not the best way to protect health needs, and abortion is a health need.”
Explore further: PL 5435/2020 had not yet been voted upon at this writing. Follow up and find out whether the bill was passed, modified, or coded into law.
To get a better sense of the reproductive disparities in the United States, we must consider maternal mortality rates. Though the maternal mortality rate in the United States declined steadily from 1900 to 1987, this statistic has increased significantly since then; in 1987, 7.2 of every 100,000 live births resulted in the mother’s death, while 26.4 of every 100,000 live births resulted in the mother’s death in 2015. This trend has been observed in no other developed nation. As a frame of reference, the 2015 maternal mortality rates in Australia, Japan, and Canada were 5.5, 6.4, and 7.3 out of 100,000, respectively (Planned Parenthood 2019).
We cannot look at these numbers in isolation. From 2011 to 2014, the rate of pregnancy-related death for Black women in America was 40 per 100,000, more than three times that for white women: 12.4 per 100,000. It is no trivial task to identify the factors responsible for this imbalance, especially as there are likely many at play. One variable that has been posited is “weathering,” which is premature cellular aging that results from the stress of racism, disrespect, and bias inherent in the medical system in the United States (Planned Parenthood 2019).
Considering that more money per capita is spent on health care in the United States than in any other country, this trend is particularly disturbing. Nonetheless, the United States is the only high-income country where employers are not required to offer paid leave to new parents. Though it is not medically recommended, nearly 25 percent of new mothers return to work within two weeks of childbirth. Furthermore, the status quo of health insurance in the United States has resulted in over 30 million Americans being uninsured, and significant proportions of those who do have insurance are underinsured. As a result, many people are unable to afford adequate medical care throughout their pregnancies and childbirths; this is particularly true among women in rural areas and among Black women. Tragically, the Centers for Disease Control and Prevention (CDC) estimates that approximately 60 percent of maternal deaths in the United States are preventable (Planned Parenthood 2019).
How do we address these shortcomings in the structural fabric of (maternal) medical care in the United States? To remedy the microaggressions that lead to a hostile environment for people of color, the Harvard Chan School Maternal Health Task Force suggests hiring a diverse staff and providing training on unconscious and overt biases. Furthermore, they vie for the importance of making prenatal and postpartum care affordable and accessible to all. Several other organizations, including the Black Mamas Matter Alliance and the Center for American Progress, are working to decrease the maternal mortality rate among Black women. Some have argued for doulas to assist with the birth of Black mothers, as they can help advocate against the biases these women are likely to face (Planned Parenthood 2019).
As these issues and systems of oppression against women of color are deeply ingrained into the medical motherhood process in the United States, the efforts of groups such as these are critical in decreasing the maternal mortality rate. Yet will they be enough, or will more radical change to our medical system be necessary?
Studies have found that the severe levels of stress that result from experiencing racism are highly impactful on maternal health. This high maternal mortality rate is found consistently among Black mothers at all levels of education and is also higher than that of Latina women, who are twice as likely as Black women to be without health care (Planned Parenthood 2019). A study that spanned across hospitals in seven states showed that hospitals that predominantly served Black patients performed worse in twelve of fifteen health care delivery indicators, including deliveries, nonelective cesarean births, and maternal mortality (Planned Parenthood 2019). The effects of racism on the outcomes of expectant mothers are incriminating, which is why it is urgent that we apply an intersectional lens when seeking solutions to our broken health care system.
Fueled by the concept of intersectionality as a source of empowerment, reproductive justice is a framework that was coined by twelve Black women in 1994 in order to “recognize the commonality of our experiences, and from the sharing and growing consciousness, to a politics that will change our lives and inevitably end our oppression” (Ross 2017, 286). Reproductive justice is defined by the core belief that every woman has the right to determine “if and when she will have a baby, to decide if she will not have a baby, and to parent the child she already has in a safe environment and healthy community without the threat of either interpersonal or state violence” (Stevens 2017). The definition thus implies that all women, including poor women, who are disproportionately likely to also be women of color, have access to free and legal abortion without barriers.
Reproductive justice is not solely about abortion, however, though abortion access is critical. A “broad approach to reproductive justice addresses aspects of women’s social status that promote or interfere with her power in relationships, bodily integrity, and ability to engage in family planning and reproductive decision-making” (Chrisler 2013, 5). It also encompasses equitable access to contraception, comprehensive sex education, STI prevention and care, alternative birth options, adequate prenatal and pregnancy care, domestic violence assistance, sufficient wages to support our families, environmental justice, and much more. In order to achieve reproductive justice, we must analyze systems of power in order to eradicate gendered, sexualized, and racialized acts of dominance (Sister Song, n.d.).
The issues surrounding reproductive justice in the United States have by no means been limited to acts of omission or matters of merely conforming to the status quo. To the contrary, those in power have actively sought out ways to harm and impair the reproductive rights of marginalized groups. The United States has a long and problematic history with eugenics, forced sterilizations, experimentation, and medical procedures without consent, particularly within vulnerable communities. In response to the momentum of the eugenics movement, US states began passing laws to permit the forcible sterilization of “feebleminded” persons in 1907. The Supreme Court upheld these controversial practices in Buck v. Bell (1927), and more than sixty thousand people were forcibly sterilized under these laws. Those who were subjected to coerced and violating procedures included people of color, immigrants, disabled people, and poor people, as well as women working in the sex industry and girls who transgressed gender and sexual norms (Manian 2020). The initial wave of support for eugenics was eventually quelled when Nazi Germany adopted similar practices, causing a shift in public opinion among US citizens and eventually leading to the 1942 Skinner v. Oklahoma Supreme Court decision to reject forcible sterilizations. Nevertheless, forcible sterilizations again gained traction here after World War II owing to anti-immigrant sentiments and population growth. The situation decades later was eerily reminiscent of that at the turn of the century: Indigenous communities, people of color, immigrants, and the poor were again the targets (Manian 2020). As laws to justify these procedures were lacking after World War II, those in power often used surreptitious means to subject these groups to sterilizations; patients were obliged to sign consent forms they couldn’t read or understand but that nonetheless permitted medical professionals to sterilize them (Relf v. Weinberger); doctors compelled their patients to undergo these procedures for fear of losing medical or welfare benefits; heavily medicated women who could not understand English had their tubes tied after childbirth (Madrigal v. Quilligan). These practices happened from coast to coast and to various racial minorities (Manian 2020). Such practices have been compared to Nazi sterilization campaigns, which were in fact modeled after eugenic sterilization laws in the United States in the early twentieth century (Manian 2020). In 1970, a whistleblower leaked evidence of rampant sterilization abuse at the University of Southern California Medical Center, where hospital staff repeatedly approached women whose primary language was Spanish for consent for sterilization while they were in active labor and with English consent forms they could not understand. And in 1974, in the case of Relf v. Weinberger, two Black sisters, aged 12 and 14, were sterilized by a federally funded family planning clinic in Alabama after their mother signed a consent form that she was unable to read (Manian 2020). These atrocities were and continue to be widespread across the United States.
Eugenics programs were also enacted within a colonial social context, once again with the belief that some people are more fit to reproduce. In Puerto Rico, fertility control was developed and fostered under colonialism after the United States seized the Caribbean archipelago in 1898 (Reichard 2020). Rich, able-bodied, white colonizers were encouraged to reproduce while poor people of color in so-called underdeveloped nations were labeled as unfit to reproduce (Reichard 2020). In 1937, Law 116 was passed, eugenics-based sterilization was subsidized and promoted by the US federal government, and the policy became so well known and normalized that it was referred to as la operación (Reichard 2020).
By the 1970s, Puerto Rico had the highest rate of sterilization in the world, with one-third of Puerto Rican women having undergone the procedure. Additionally, US eugenicist Clarence Gamble, heir to the Proctor and Gamble fortune, enacted another method of reproductive violence by using his facilities on the archipelago to test contraceptives that had not been approved by the US Food and Drug Administration on fifteen hundred women, many of whom lived in in impoverished neighborhoods (Reichard 2020). None of the deaths caused by the trials were investigated. Currently, in Puerto Rico, almost half the population lives below the poverty line, further complicating any sort of reproductive freedom. Some birth control methods, such as intrauterine devices, can cost more than $1,000, and other options such as the patch or the pill range from $10 to $150 a month (Reichard 2020).
Sterilizations in 2020 reflect US history over the past five hundred years, where people who have been deemed “undesirable”—women, girls, people of color, people with disabilities, and people who have been convicted of crimes—are considered unfit to have children and are subject to horrendous medical violations (Deaderick 2020). There are many forms of violence that the United States has inflicted on Black, Indigenous, Latinx, and other communities of color, including genocide, enslavement, and family separations. These forced sterilizations represent reproductive violence that is the implementation of racist and eugenic practices executed by the federal government.
Tragically, a new wave of forced sterilizations in the United States arose in 2020. Dawn Wooten, a whistleblowing nurse from the Irwin County Detention Center in Georgia, detailed how officials and medical professionals have been violating the rights of countless immigrants at this facility. Wooten described how women were frequently subjected to “forced hysterectomies and other unwanted gynecological procedures,” and informed consent was lacking (Manian 2020). Without professional interpreters, some nurses attempted to use cursory tools such as Google Translate to communicate with their patients; nonetheless, many of these patients could not understand what was happening to them. Again, for at least the third time in US history, these practices target particularly vulnerable groups, solidifying just how perilous it is to be an immigrant, a person of color, or poor in the United States (Manian 2020).
Anti-Trans Violence and Trans Care
Transgender, gender-diverse, and nonbinary people experience high rates of health disparities and violence. A total of 350 known trans and gender-diverse people were murdered globally in 2020, indicating a 6 percent rise from 2019 (Clifton 2020). Trans women or transfeminine people accounted for 98 percent of those killed, and 79 percent of trans people murdered in the United States are people of color (Clifton 2020). It is also important to remember that many cases of trans murders aren’t known to the public, as they are under- or misreported. Trans people of color, particularly Black trans people, are more likely to experience discrimination and violence in housing, employment, and health care, while also being 6.2 times more likely to experience police violence and 1.6 more times likely to experience physical violence (SPARK Family 2015).
The trans community is a diverse population with a high prevalence of adverse health outcomes (Reisner et al. 2016). Though, overall, most aspects of health remain understudied and lacking, the most prominent outcomes among trans communities include HIV and other STIs, mental health distress, and substance use and abuse. The lack of resources invested in minimizing health inequities in the trans community implies a dire need to acknowledge the complex ways that institutional systems operate to create these inequities in health outcomes in the first place.
Our institutional systems have stigmatized trans people for decades. In 1975, gender transition processes were classified as a mental disorder within diagnostic classification manuals, including the International Classification of Diseases (ICD). The ICD and Diagnostic and Statistical Manual of Mental Disorders only recently removed this classification. Nevertheless, trans people still suffer the daily repercussions of transphobic laws and practices, social discrimination, and violence, both inside and outside the medical community. In several countries, they are still required to undergo psychiatric treatment to access trans health care and are often subject to reparative therapies. Scientific literature has also historically pathologized trans people (Schwend 2020).
Efforts are being made to address these inequities. The Human Rights in Patient Care Framework helps to prevent abuse within the health care system and hold governments accountable. The Yogyakarta Principles, published in 2007 and updated ten years later, establish a basis of human rights laws to protect people from discrimination based on gender expression, sexual orientation, and sex characteristics. Nevertheless, the situation has by no means been made right, as trans people still suffer widespread discrimination in health care and employment, and they are highly exposed to a spectrum of human rights violations (Schwend 2020).
by Qamar Ahmed
Since 2018, coalitions of feminist organizations across Pakistan have been taking to the streets on International Working Women’s Day, under the banner “Aurat March” (which means “Women’s Freedom”) or “Aurat Azadi March.” They demonstrate for the liberation of Khwaja Siras (third-gender people), transgender people, nonbinary people, and women, and for the abolition of patriarchy and all forms of gender oppression and exploitation.
Ahead of its 2021 demonstration, Aurat March Lahore issued a comprehensive “Feminist Manifesto on Healthcare.” The manifesto calls for universal access to health care for all people “regardless of gender identity, financial/social class, religion, sexual orientation, race, ethnicity, dis/ability and citizenship.” Staunchly opposed to the privatization of health care in Pakistan, it specifically advocates transforming the health care system to fully and equitably meet the needs of Khwaja Sira communities, transgender people, disabled people, working-class women, people living with HIV, survivors of abuse, drug users, sex workers, and incarcerated women and children.
Specific demands include access to hormone therapies, drug recovery programs, HIV/AIDS medications, medical care for disabled people and for sex workers, and an end to forced sex-assignment procedures on intersex people.
Similarly, the Aurat Azadi March’s Charter of Demands, titled “Feminist Care in the Time of the Coronavirus” for 2021, addressed health care, disability justice, patriarchal violence, labor rights and protections, welfare, affordable housing and land redistribution, militarized state violence, students’ oppression, justice for religious and ethnic minorities, and environmental justice.
Select demands from this charter include free health care for people with mental and physical disabilities, taxation and environmental regulation of corporations, universal basic income, land redistribution, an end to enforced disappearances, demilitarization of educational institutions and reinstatement of student unions, legislation against forced conversions, and an end to police brutality, harassment, and murder.
As Loretta Ross explains, intersectionality through a reproductive justice lens is crucial to address reproductive vulnerabilities. She writes,
Not only biologically defined women experience reproductive oppression. By highlighting the distinction between biological sex and socially constructed gender, our analysis includes transmen, transwomen, and gender-nonconforming individuals. For example, trans and intersex people are frequently coerced to undergo gender reassignment surgery that results in involuntary sterilizations in order to obtain vital identity documentation such as driver’s licenses that match their preferred identities. Such policies limit their reproductive options as a form of covert reproductive control by the state. Reproductive justice addresses the essentialism of gender-specific accounts that neglect how differences shape people’s material realities, leaving undiscovered reproductive vulnerabilities shaped by white supremacy and neoliberalism. White supremacy as used in this article is a lethal body of ideas comprised of racism, Christian nationalism, homophobia, nativism, settler colonialism, transphobia, misogyny, and authoritarianism. (Ross 2017, 292)
Ross’s words demonstrate the need for an intersectional framework to understanding health inequities and an approach to reproductive justice that is inclusive of all people and centers the experiences, needs, and power of those who are most marginalized.
In the words of Audre Lorde, “There is no such thing as a single-issue struggle because we do not live single-issue lives” (2007, 131). All forms of oppressions affect reproductive lives, so marginalized groups, who experience multiple layers of structural oppression, need to be at the forefront of conversations on reproductive justice.
The COVID-19 pandemic has focused attention on the health disparities experienced by people with disabilities. Individuals with disabilities have historically been erased and mistreated by the institutional systems of white supremacy, heteropatriarchy, colonialism, and capitalism. Before the disability rights movement, public places were inaccessible, and people with disabilities were mistreated without legal repercussions. This movement critically established civil rights for people living with disabilities through the creation of organizations and movements such as service provision agencies, constituency-led centers, academic spaces, and advocacy organizations (Sins Invalid 2020).
Nevertheless, while the disability rights movement was important in raising awareness and demanding civil rights, both its context and content lacked in several regards. For one, its approach often based disability rights on a single issue rather than considering the disabled person as a whole (e.g., immigration status, race, gender, sexuality); the importance of intersectionality should be noted here. Furthermore, the leadership of the disability rights movement was based on white experience and privilege, and a more diverse framework is necessary to comprehensively serve all disabled people. The mainstream disability rights framework also historically focused on people with mobility impairments, with other disabilities being relatively neglected. Achieving justice through this movement has often hinged on pursuing a legal pathway, but this option is not always available or appropriate (Sins Invalid 2020).
In response to these shortcomings, queer disabled persons and people of color spearheaded a movement for disability justice in 2005, with activists like Patty Berne and Mia Mingus leading many of these first initiatives and conversations. Central to the tenets of this movement is the idea that “disability justice work is largely done by individuals within their respective settings” (Sins Invalid 2020). Also pivotal is the fact that leadership is composed of disabled persons that offer diverse perspectives (e.g., queer, gender-nonconforming, people of color). Through these efforts, the disability justice movement seeks to create “a world that values and celebrates us in all our beauty,” with a focus on the principle that “we move together, with no body left behind” (Sins Invalid 2020).
Ten Principles of Disability Justice
from Sins Invalid
- Intersectionality: Simply put, this principle says that we are many things, and they all affect our lived experience. We may be not only disabled, but we also each come from a specific experience of race, class, sexuality, age, religious background, geographical location, immigration status, and more. Depending on context, we all have areas where we experience privilege as well as oppression. The term intersectionality was first introduced by feminist theorist Kimberlé Crenshaw in 1989 to describe the experiences of Black women, who experience both racism and sexism in specific ways. We gratefully embrace the nuance that this principle brings to our lived experiences and the ways it shapes the perspectives we offer.
- Leadership of Those Most Impacted: When we talk about ableism, racism, sexism and transmisogyny, colonization, police violence, and the like, we are not looking to academics and experts to tell us what’s what—we are lifting up, listening to, reading, following, and highlighting the perspectives of those who are most impacted by the systems we fight against. By centering the leadership of those most affected, we keep ourselves grounded in real-world problems and find creative strategies for resistance.
- Anti-Capitalist Politics: Capitalism depends on wealth accumulation for some (the white ruling class) at the expense of others and encourages competition as a means of survival. The nature of our disabled body/minds means that we resist conforming to “normative” levels of productivity in a capitalist culture, and our labor is often invisible to a system that defines labor by able-bodied, white supremacist, gender-normative standards. Our worth is not dependent on what and how much we can produce.
- Cross-Movement Solidarity: Disability justice can only grow into its potential as a movement by aligning itself with racial justice, reproductive justice, queer and trans liberation, prison abolition, environmental justice, anti-police terror, Deaf activism, fat liberation, and other movements working for justice and liberation. This means challenging white disability communities around racism and challenging other movements to confront ableism. Through cross-movement solidarity, we create a united front.
- Recognizing Wholeness: Each person is full of history and life experience. Each person has an internal experience composed of our own thoughts, sensations, emotions, sexual fantasies, perceptions, and quirks. Disabled people are whole people.
- Sustainability: We learn to pace ourselves, individually and collectively, to be sustained over the long term. We value the teachings of our bodies and experiences and use them as a critical guide and reference point to help us move away from urgency and into a deep, slow, transformative, unstoppable wave of justice and liberation.
- Commitment to Cross-Disability Solidarity: We value and honor the insights and participation of all of our community members, even and especially those who are most often left out of political conversations. We are building a movement that breaks down isolation between people with physical impairments, people who are sick or chronically ill, psych survivors and people with mental health disabilities, neurodiverse people, people with intellectual or developmental disabilities, Deaf people, Blind people, people with environmental injuries and chemical sensitivities, and all others who experience ableism and isolation that undermines our collective liberation.
- Interdependence: Before the massive colonial project of Western European expansion, we understood the nature of interdependence within our communities. We see the liberation of all living systems and the land as integral to the liberation of our own communities, as we all share one planet. We work to meet each other’s needs as we build toward liberation, without always reaching for state solutions that inevitably extend state control further into our lives.
- Collective Access: As Black and brown and queer crips, we bring flexibility and creative nuance to our engagement with each other. We create and explore ways of doing things that go beyond able-bodied and neurotypical norms. Access needs aren’t shameful—we all function differently depending on context and environment. Access needs can be articulated and met privately, through a collective, or in community, depending upon an individual’s needs, desires, and the capacity of the group. We can share responsibility for our access needs, we can ask that our needs be met without compromising our integrity, we can balance autonomy while being in community, we can be unafraid of our vulnerabilities, knowing our strengths are respected.
- Collective Liberation: We move together as people with mixed abilities, multiracial, multi-gendered, mixed class, across the sexual spectrum, with a vision that leaves no body/mind behind. This is disability justice. We honor the long-standing legacies of resilience and resistance that are the inheritance of all of us whose bodies and minds will not conform. Disability justice is not yet a broad-based popular movement. Disability justice is a vision and practice of what is yet to be, a map that we create with our ancestors and our great-grandchildren onward, in the width and depth of our multiplicities and histories, a movement toward a world in which every body and mind is known as beautiful.
Transnational Engagements and Health Equity: A Way Forward
Throughout the world, women are addressing inequalities that deny their human rights, endanger their health, keep them from productive opportunities, and threaten them with violence. This happens in various settings: within the family, in schools, and in commercial and political institutions. Women’s social, economic, and political status undermines their ability to protect and promote their own physical, emotional, and mental health, including their effective use of health information and services. Women deserve better.
The inequities ingrained in the daily lives of women have been exacerbated by COVID-19. With more time spent at home during the pandemic, the hours devoted to domestic work such as meal preparation, cleaning, and child care have increased dramatically, and the brunt of this labor has fallen upon women. This division of household labor was already severe before the pandemic, with 42 percent of women unable to maintain a paid working position because of their domestic responsibilities, in contrast to 6 percent of men. The unpaid and domestic workload also increased for men during this time, but it has increased more significantly for women (Bolis et al. 2020). The effects of this disparity cannot be neglected. Among women surveyed about the changes to their lives and workload during the COVID-19 pandemic, 43 percent reported heightened levels of anxiety, depression, and isolation; they also noted feeling overworked and becoming physically ill due to these unpaid responsibilities. Furthermore, this disparity is more rampant in lower-income countries, with women there shouldering even more responsibilities and lacking the means that might make their labor less onerous (e.g., labor-saving equipment, water, electricity) (Bolis et al. 2020).
Gender equality is a goal in its own right, and it is central for the attainment of social policies in a wide range of areas, including the improvement of health. As this chapter emphasizes, we must address discrimination based on gender, race, ethnicity, caste, sexual orientation, migrant status, nationality, and other statuses and health care practices by using an intersectional framework to ensure that interventions in health benefit those who have the least resources. Changes are occurring, but not quickly enough. A woman dies in pregnancy or childbirth every minute. One in three women experience gender-based violence in their lifetimes. In 2020, 2.3 million women were diagnosed with breast cancer, resulting in 685,000 deaths globally. Trans people experience high levels of violence, discrimination, and stigma that also limit their access to much needed health care. Armed conflict disproportionality affects the well-being and health of women and children (Singh et al. 2021). And too many women are not receiving the benefits of their productive labor. Women want a different future.
Change must take place at the local level as well as within international policy. In other words, it is imperative to realize the importance of community-based and grassroots approaches to health issues that are inclusive of marginalized voices. These efforts require collaborative action by a wide range of actors outside the government and development agencies, such as people’s organizations, community-based organizations, underrepresented and marginalized women’s groups at the local and national levels, the media, and all others concerned with building a fair and just society. To obtain health equity, we must call out and dismantle the systems that perpetuate inequality. Such collective action creates pressure for accountability and puts social change onto the political agenda. Activist Peggy Antrobus (2004, 25) identifies the “common difference” that “links us all in a political struggle for recognition and redistributive justice.” She explains that its difference from other social movements “lies not only in the absence of homogeneity . . . but in the value it places on diversity, its commitment to solidarity with women everywhere, its, feminist politics, and its method of organizing.” And, as Rhoda Reddock states, “sexuality and reproductive rights and health, including freedom from violence, are the foundation of women’s ability to engage in the political struggle against inequality and injustice, not just for women but for everyone” (Antrobus 2006, 1375).
Recognizing the connections between individual health and community health makes it vital that all research, policies, and programs/projects are committed to achieving health equity in a systematic and sustainable manner. Such goals cannot be achieved through isolated actions by any one group of society, no matter how committed. The root causes of these problems and power relations must be identified, and a feminist, human rights perspective must be employed to understand health in the context of wider social, cultural, and economic issues. Thus the priorities for equity should be identified and based on the community’s struggles with colonialism, imperialism, and neoliberal national and oppressive policies within global and transnational sociohistorical contexts. The challenges to eradicating health inequities and shifting the distribution of power across all social institutions cannot be addressed merely through technical or managerial interventions, but instead require an emphasis on social justice and health equity through intersectional practices and policies.
- Shirazi begins the chapter by arguing that health and adequate health care are a human right. What does/should the right to health and health care include, according to Shirazi and the sources she cites?
- Shirazi discusses the ways that COVID-19, environmental changes and disasters, and war have negatively affected—and continue to negatively affect—health outcomes for women and girls around the globe. Working alone, with a partner, or in a small group, choose one of the three topics listed above. How does Shirazi support her argument about the way COVID-19, environmental changes and disasters, and war negatively affect health outcomes for girls and women? What do you learn about your chosen topic that you didn’t previously know?
- One chapter heading asks, “Why Do Women Still Die Giving Birth?” How does Shirazi answer that question?
- What is the global gag rule? How does this US foreign policy negatively affect women around the globe?
- What is reproductive justice? How does the concept of reproductive justice broaden the conversation about reproductive rights beyond a pro-choice / pro-life framework?
- What is “the way forward” to health equity, according to Shirazi? How do transnational feminist theories and principles serve as the foundation for the way forward?
- Working in a small group, add these key terms to your glossary: Sustainable Development Goals (SDGs), Majority World / Minority World, global gag rule, medical racism / medical apartheid, reproductive justice, disability justice.
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