In this chapter we examine some of the major factors affecting women's health, approaches made by development agencies, and some of the ways in which women themselves are dealing with matters affecting their health. Emphasis is on women-determined health programs, research and practice. There is a descriptive list of women-oriented health groups in different parts of the world and a selected bibliography.
This chapter was written by Jane Cottingham.
women and health overview
Jane Cottingham
Health touches every part of our lives. It is by no means only a question of curing diseases or preventing them. The right to health means not only the right to be free from disease, it also means physical, emotional and mental well-being. Health has to do with all aspects of our lives, from the'kinds of food we eat to the kind of house we live in and the kind of work we do. Health cannot be separated from the political, economic and cultural systems of our societies. It cannot be isolated from our roles as women within these societies.
In many ways women and health are synonymous. Our roles as care-givers and our potential for using any health system make us central to health. Cultural and geographic differences are, of course, enormous, yet women's centrality to health cuts right across these differences. Consider the following:
- as mothers we are responsible for the health of our children and families, for providing food for them and caring for them when they are sick;
- as potential mothers we face the problems of repeated pregnancy, of contraception and abortion;
- as workers both in production outside the home (usually concentrated in low-paying jobs) and within the home, we are over-worked, over-tired, subject to poor working conditions and exposed to a multitude of health hazards;
- as consumers for the family, we are susceptible to advertising about health, food, medicine etc.;
- as women we are subjected to laws and systems of health made by men, and not geared to our needs or those of our children;
- as objects of desire or possession, we are expected to correspond to certain ideas of beauty and "womanhood", thus being vulnerable to encouragement by industry (and others) to buy beauty products, to fight old age, or to undergo plastic surgery for "beauty" purposes; or we are mutilated to conform to certain standards of sexuality or virginity;
- as women confronted by and confined to all these roles, we are treated as mad for not adjusting to them, and given drugs or locked up as a solution.
Women are central to health. We are the majority of workers in all health systems of the world. Yet two startling facts have to be pointed out: first we have little or no control over the health systems or kinds of care given; second, in most societies our health is not improving. On the contrary. It has declined in many of the poorer countries of the world, while in the richer countries other, often medically or socially induced illnesses are on the increase. Why?
health systems: the medicalization of society
Over the past three decades health care and services have been increasingly defined in terms of medicine and medical care, rather than in terms of those activities and behaviours which actually produce health, or ill-health. This is true of both industrialized and developing countries. Water, food, air, and lifestyle or life stress are conceded by most public health researchers to be the major determinants of health, rather than the activities of the medical profession. Yet most countries continue to pour out increasing resources for curative, high technology medicine, which is not only extremely costly but also requires modern, western-style institutions and expensively-trained personnel to administer. This type of care usually benefits only an urban elite population which can pay for "modern" care) while long-term investments in public health, such as eliminating pollution, providing water, sanitation, access to food and vaccination - measures which could ultimately guarantee an equitable standard of good health for the majority — are by-passed.
There are many instances of money being poured into enormous modem hospitals in areas where the majority of the population does not have access to clean water or adequate sanitation. In Lesotho, for example, a newly-built hospital costs US$4.6 million per year to run, whereas the entire health budget is only US$3.2 million.' In Yemen, the hospitals in the three largest towns, catering for only seven percent of the population, contain more than one half of the doctors in the country and 60 percent of all trained nurses.2
Although such examples are shocking in developing countries, a similarly skewed situation appears in industrialized countries, where emphasis put on drugs and medicines far outweighs the importance given to a good balanced diet.
the pharmaceutical industry
The growth of "medical care" as opposed to "health care" is intimately connected with the development of the pharmaceutical (drug) industry. The pharmaceutical industry is one of the most profitable in the world. Studies show that since the mid-1950's it has consistently recorded profits that are substantially higher than the average for all industry in both the USA and the United Kingdom, and was often the most profitable manufacturing industry.
The development of the multinational drug companies dates from the 1940's when expansion of the petro-chemical industry on which they are based, was at its most rapid. At first many small companies mushroomed, but these have since been swallowed up to the point where, for instance, in Britain, five companies control 30 percent of the market, in the USA ten companies control over 40 percent and the three Swiss firms, Ciba Geigy, Sandoz and Hoffmann La Roche account for some 15 percent of world sales.3
The structure of industry is highly complex, since like all multinationals (with one or two exceptions), these companies have branched out from the simple manufacture of chemical-based medicines. They are now involved in producing and marketing everything from fertilisers, insecticides and special kinds of food grains, to soaps, detergents, cosmetics and perfumes. They are as much involved in making products for chemical warfare as vitamins and baby foods. The direct impact of drug companies' activities on women's daily lives especially is thus enormous. The fact that women are the biggest consumers of drugs worldwide from contraceptives to "psychoactive" drugs, and that they are most crucially affected by the dangers of pesticides, fertilizers or chemical warfare products means that the pharmaceutical industry plays a central role in the "health" of women.*
*One example is the explosion in July 1976 in Seveso, Northern Italy, caused by the faulty operating of the only safety valve at the ICMESA chemical plant there. A huge noxious black cloud spread over the area, and after 20 days 46 people had been hospitalized. At the end of two months, an area of nearly 350 hectares was declared contaminated and more than 2,000 people were evacuated. The poison which had escaped was dioxin, one of the most dangerous chemicals in the world, whose effects are slow and long-lasting, sometimes only becoming evident after one generation. It penetrates the skin, the blood, the liver, the kidneys, the stomach, the lungs and the central nervous system. It causes cancer and genetic mutations (changes in the species). It also attacks pregnant women and their unborn babies. Several women managed to get abortions, but one woman gave birth to a stillborn baby without a brain, and children born since have suffered from stomach abnormalities. The full effects of this contamination will only be known after 20 - 25 years. ICMESA is a subsidiary of Givaudan, a Swiss chemical and cosmetic manufacturer owned by Hoffmann-La Roche, the biggest pharmaceutical company in the world, best known for its top-selling tranquilizers, Librium and valium4.
Whereas it is true that some research on drugs has undoubtedly grown out of very specific health needs, such as vaccines against dire diseases like small pox, yellow fever and tetanus, it is also true that currently 50 times more money is spent on researching cancer than on all the tropical diseases put together.^ A tremendous amount of research is done into drugs which will be profitable. Pharmaceutical companies compete for markets with their own "brand name" products which are one particular company's version of, say, a pain killer. The generic name, e.g. aspirin, will become "Kenalgesic", "Majoral", "Aspro" etc.* Companies may produce any number of slightly differing formula for a drug in order to gain increased access to the market. They will also spend valuable research money on producing their own, patentable version of a drug already in existence. Brand names cost more because the company has to spend money developing and promoting the product. What is more, they are able to charge whatever prices the market will bear, and this is often vastly different from one country to another. Tricks like "transfer pricing" — "selling" the active ingredients of a drug to a subsidiary for production in a developing country — enable the company to increase profits even more.
In effect, the pharmaceutical companies will influence health care by investing in drugs which they think will sell. This involves developing ever more sophisticated versions of drugs which may not necessarily be a solution to a health problem and indeed may provoke additional problems. The development of "psychoactive drugs" is one such area. Psychoactive drugs comprise anything from tranquilizers to behaviour modifiers. In the USA, 67 percent of psychoactive drugs are given to women, and each year one-third of women over the age of 30 receives prescription tranquilizers, stimulants and/or anti-depressants.'' Vitamin injections are another example given frequently to people everywhere as a "solution" to fatigue. Neither of these drugs ultimately improves the health of the taker, and certainly does nothing to address the cause of the problem. "Pain killers, so-called health foods and tonics and other hope-giving pills only add to the confusion and misery of the people. Enormous amounts of money are spent on dubious medicines. Drug production and distribution has no relation to the real health needs of the country."8
The companies' major outlets are, of course, the health systems - doctors, nurses, hospitals, clinics, pharmacies and drug stores. In order to promote their drugs, the companies will inevitably influence the health systems, using the whole array of advertising gimmicks available, from free samples and product-stamped stationery to frequent visits by the company representative and funding for research or conferences. They thus have considerable influence on the kinds of care provided, and to some extent on the very concept of such care. One report from Bangladesh stresses:
Medical education doesn't include instruction in the economics of drug production/marketing and its social implications. Consequently, patients are deprived of nutrition education which should be given instead of alcohol-addicting vitamin tonics. A poor man will often pay as much as one half his weekly wage to obtain a drug that could well be harmful to him and at most, is probably useless or unnecessary. Our estimate of the ratio of drug representatives to doctors in Bangladesh would be 1:7. In Tanzania it is 1:4 while in Britain 1:20. These marketing representatives are guilty of "conning" doctors and consumers alike into identifying the healing properties of drugs with brand names (and therefore higher prices). This is made all the more easy by the fact that the only promotion material available is provided by the drug company and is usually in a language which is foreign to the person prescribing as well as to the person buying. To stop such exploitation the health profession needs continued education and consumers need access to the "restricted" information about the drugs they are prescribed to take.9
The World Health Organisation has recognized this problem and has developed a "model list of essential drugs" listed by generic names only and numbering around 200. The implications for governments of applying such a list in practice, though, are enormous. In a country like India at least 30,000 branded drugs are sold, and reducing these to less than one percent — the 116 generic drugs which can satisfy the basic drug needs of the country'" - would mean a major revolution both in the country's health care system and in its trading. It is hard to imagine pharmaceutical companies willingly accepting such a situation.
the health profession
As a major dispenser of pharmaceutical products, the medical profession plays a crucial role in the medicalisation process. The profession is an old establishment which has built up its prestige over several centuries. This prestige, and the transformation of healing into a "profession" has been created by a long struggle from which men emerge dominant. Ehrenreich and English describe it this way:
Women have always been healers. They were the unlicensed doctors and anatomists of western history. They were abortionists, nurses and counsellors. They were pharmacists, cultivating healing herbs, and exchanging the secrets of their uses. They were mid-wives, travelling from home to home and village to village. For centuries women were doctors without degrees, barred from books and lectures, learning from each other, and passing on experience from neighbor to neighbor and mother to daughter. They were called "wise women" by the people, witches or charlatans by the authorities. Medicine is part of our heritage as women, our history, our birthright.
Today, however, health care is the property of male.professionals. Ninety-nine percent of the doctors in the US are men; and almost all the top directors and administrators of health institutions. Women are still in the overall majority - 70 percent of health workers are women - but we have been incorporated as workers into an industry where the bosses are men. We are no longer independent practitioners known by our own names, for our own work. We are, for the most part, institutional fixtures filling faceless job slots: clerk, dietary aid, technician, maid...11
They explain how this struggle was political, linked both to the decline in the status of women generally, and to class: women healers were people's doctors, whereas male professionals served the ruling class, and their interests were advanced by universities, philanthropic foundations and the law, all of which excluded women.
The authors are, of course, describing industrialized countries and in particular the USA. There, the women's health movement is challenging this domination and "professionalism" and women are beginning to re-learn the ancient arts of healing. In other parts of the world women are still major healers and care givers, although health planners have totally ignored this.
In many third world countries, the health system has developed from the western male-dominated services brought by the colonisers for their own use. This means that large sophisticated hospitals have been built which must be run by people who receive training in the West. This has produced an absurd situation where, in West Africa, for instance, a doctor's training costs the equivalent of a peasant's income for 100-200 years. These people are, of course, nearly always men. Thus when he has finished this training, the doctor finds it totally inappropriate to the problems he has to deal with in the country, both because it is too technical and because it does not apply to the people who need health care most - malnourished women and children. He has become a member of a privileged class, removed both by his language, foreign to the indigenous population, and by the position he gets in the hierarchical health system in his own country (based on western models). Women in third world countries are the particular victims of this medical classism and sexism since (a) they are potentially greater users of the services because of their role in childbearing and caring, and (b) a high proportion of them are illiterate.
In the West, most women are not illiterate, but the prestige of the medical profession still keeps them in awe. They often do not know what is wrong with them until they have been to a doctor, and they expect the doctor to give them pills. In 1974, doctors in Britain wrote an average six prescriptions for every woman, man and child.
governments
Clearly governments are also implicated in this situation. The colonial legacy of many third world countries leaves them increasingly dependent on the pharmaceutical industries as employers, investors and sources of taxable revenue. They receive aid in the form of hospitals, research units and trained personnel from the rich countries. In Bangladesh, for instance, ninety percent of the Government spending on health goes to six percent of the people, and the wealthiest are found in that six percent, not the poorest. Medical students are still trained to meet the needs and stresses of the wealthy, and are taught nothing of the so-called "tropical diseases." In Tanzania, spending on drugs now accounts for 28 percent of the Tanzanian Health Ministry's allocation, compared with 11 percent in Britain.
There are exceptions, though. Studies indicate that countries which have tried consciously to take a different route system. Mozambique, for instance (population 18-19 million) has 35,000 health instructors of various grades after 10 years of independence whereas Tanzania (population 12-13 million) had only 323 health instructors after the same period.'12 The example of China is frequently cited as a model for popular health systems, and there may be lessons to be learned from that country.
health as a development concept
Unfortunately, the western model is undoubtedly the dominating one, and this has grave implications for women in botht industiralized and developing countries . "Health" as one concept in the development packet was almost universally taken to mean promoting curative medicine. Until the early 1970's the World Health Organisation was uncritically promoting the system of western medicine: the massive introduction of medical technology, drugs, hospitals, surgical intervention and all the attendant expertise and equipment. As we -know, this did little to reach most of the world's populations - the rural poor. Indeed, still today, three-quarters of third world doctors work in cities where three quarters of the health budget is spent. But three-quarters of the people and three-quarters of the ill-health are in the rural areas.
In 1975 WHO director Halfdan Mahler admitted, "In spite of tremendous strides in medicine and technology, the health status of the majority of people in disadvantaged areas of most countries of the world remains low."13
In the 1970's a radical rethinking took place, and the Alma Ata Conference of WHO and Unicef in 1978 launched the concept of "Primary Health Care". Primary Health Care (PHC) is defined as "essential health care that is accessible, affordable and acceptable to everyone in the country." It implies a variety of approaches including promotive, preventive, curative and rehabilitative action. It should cover: nutrition, adequate safe water, sanitation, maternal and child health including family planning, treatment of common diseases and injuries, immunization, prevention and control of locally endemic diseases, and health education. As one document says, PHC is about ditches, water, pipes, nutrition, latrines and contraceptives.The approach is revolutionary in that it officially regards health as being related to a whole gammut of things, and not just lack of disease or availability of medicines.
The promotion of PHC is only just beginning, so it is too early to know what the impact is. However, although social, political and economic factors are raised in PHC, it is not clear that they can or will be dealt with. For instance, providing water to a village in, say, India, by the sinking of a tube well raises the question of whose land it shall be sunk on and who (in a caste system) has priority access to it. Training village health workers may raise their status so much above that of the villagers that they and their ideas are no longer accepted. "There is an unresolved conflict of interest.between those who have power,money and knowledge, and those who have none", says one Norwegian doctor who worked for seven years in Botswana. She goes on, "Health education has revolutionary potential if it leads to awareness, organization and action. But if people are to participate in a real and relevant way in their own health care, it means they also have to participate in the control and exercise of power."15
A major problem which seems to be surfacing already, though, is that PHC has to do with "self-help". In industrialized countries, the women's health movement has used the term "self-help" to denote the taking back of power over their own bodies, until now usurped by the medical profession. But in developing countries the situation is totally reversed: the vast majority of women have no access to any kind of health care system, and where it exists it is inadequate and probably expensive. The notion that one should "care for oneself then is dangerous. It can come to be viewed as a means for governments to withdraw all attempts to provide health care services, with significant consequences for women. As Padma Prakash points out, "Unless sex-typing of roles in a family is rooted out, it will only mean an extra burden on the woman of the house."16 The assigning to women of yet another unpaid, unrecognized job in the home can have nothing to do with development. In this respect, the PHC report from the Alma Ata conference gives little grounds for jubilation when it says, "women can contribute significantly to PHC especially during the application of preventive measures", but men can "contribute by shaping the community health system".17
population, maternal and child health
Nonetheless, PHC is a welcome advance in that it promises to address problems of women's health in all areas. Until now, when considered separately at all, women have been seen uniquely in their role as child bearers. Maternal and child health services have been the traditional "women's health" units, where on the other hand, women's malnutrition, fatigue and overwork, stress and the environment, have been barely addressed.
This approach has been complicated with the absorption of "population problems" into the area of health. In 1960 WHO was prohibited by its member states from having anything to do with family planning. It was during the 1960's that the rapid rate at which the world's population was growing became an urgent concern, and in 1969 the United Nations Fund for Population Activities (UNFPA) was set up.
UNFPA's job is to "play a leading role in the UN system in promoting population programmes on the problem of fast population growth as well as on the problem of under population, which could, among other things, hamper rapid economic development".18
This "concern for the world's population" has been reflected in the enormous rise in the number of non-governmental agencies dealing with the "population problem", from the International Planned Parenthood Federation and the Pathfinder Fund, to population research centres and councils. The concern, however, has frequently been translated into aggressive policies of stopping women's fertility at all costs. Indeed, it was rarely if ever seen in terms of women's health, but only of limiting the number of people. The women's movement internationally has played a crucial role in documenting the results of this approach - from forced sterilization, to the mass introduction of any form of contraceptive, however harmful. The approach has had two major effects: first, that women's health issues have tended to be relegated to and defined entirely in terms of their reproductive capacities; second, that the whole issue of family planning (often called "population and development") has become crucial in development thinking, with theories that population control can solve the "development" issue, and practices which alienate and dehumanize people. It has done little to help women take control of their own lives.
The notion that women might want to control their fertility for their own and their children's health is one that is only just beginning to surface in population thinking. The concern that women's health might be improved by limited births — that this might benefit their own and their children's situation — has not been a motivating force, by and large, in the population control establishment.
Abortion, contraception and sterilization are among the fundamental issues of concern to women and their health everywhere. Forced sterilization in some countries (e.g. Puerto Rico) is matched with the difficulty in obtaining sterilization when desired in others (e.g. France). Contraception is characterized the world over by mostly inadequate, unpleasant or harmful products. In some countries they are more available than others. Abortion laws may be liberal or highly restrictive depending on the natalist policies of the government in conjunction with religious forces; but they have little to do with concern for women and their health. Illegal abortion remains the greatest women's health problem in the world, with thousands of women dying every day and thousands more becoming sterile later from infections.
The issue for women is contraception — being able to control their fertility, with the widest range of options possible, and full information on side-effects and follow up care when necessary. Continuous pregnancy and childbirth are tiring and ultimately debilitating and dangerous; the fight for good, safe, cheap and available methods of contraception is clearly a major priority for women and their health.
nutrition
e know that dietary deficiencies caused by lack of food have grave effects such as blindness caused by lack of vitamin A, scurvy and lowered resistance by lack of vitamin C, rickets by lack of vitamin D, fatigue by lack of iron. Lack of food generally greatly increases susceptibility to infection and disease.
However, malnutrition is still one of the greatest causes of death in the world. "In spite of increasing per capita food production, hunger and malnutrition are increasing in both developed and developing countries. According to the latest data from FAO, the number of hungry and malnourished increased from 401 million people in 1970 to 455 million in 1974 in the developing countries alone."19
For many years, the causes of malnutrition were seen as ignorance or lack of motivation on the part of the individual and the failure of individuals to use the existing resources properly. Traditional nutrition education programmes were (and still are) geared to attacking this ignorance. Women have been regarded as central in this process. As one study on women in Africa describes it:
Women are regarded as medical cases, particularly vulnerable to adverse nutritional conditions because of their reproductive functions and therefore needing-specific curative and preventive care in order to improve their biological role in nutrition. Secondly, women are regarded as social actors responsible for other people's nutritional conditions, usually on the assumption that this role can be strengthened by improving their knowledge and practices by educational measures alone.20
In this context development programmes have been aimed at educating women in food values, food preparation and conservation, with everything encompassed in the "home economics" approach.
While not necessarily negative as such, this approach has been totally inadequate in that it ignores the whole range of factors involved in what people eat and why. In some developing countries there are food taboos ~ certain foods which women may not eat. There may also be customs whereby men eat first, taking the lion's share, and women last, eating whatever is left. (The study cited above warns, however, that food taboos have often been used to explain why nutrition programmes fail, and that it would be better to look at the broader issue of power structures within a society.)
Emphasis of nutrition programmes on pregnant and breastfeeding women, while useful in some ways, have been singularly lacking in perspective too. Kamala JayaRao writes, "The reason is, firstly that in such an approach the female is viewed only in the context of her motherhood and, therefore secondly, the problem is seen in isolation. The problem should be understood as fundamentally an offshoot of a deeper and more complex malady, namely the inferior and status and expendable nature of the female in Indian society."21
What is clear is that women play a central role in food production, handling and nutrition whether or not they are pregnant or breastfeeding. In the developing world 50—90 percent of agricultural workers are women. In all countries of the world they prepare, preserve and cook food. Yet this situation in no way reflects the control which women have over food production or what is consumed. A complex web of interrelated factors affects this: access to land, policies of agricultural production affected by patterns set up under colonialism and continued in trade agreements today, migration from rural to urban settings, multinational food companies' priorities, changes in kinds of food consumed, food aid, cost of food. The earlier chapter on Rural Development — section on women and food production — deals with many of these aspects in more detail.
It is important to add here that world patterns of food production are geared to high profit-making and have little to do with healthy eating. Wheat, for instance, one of the major food staples of the world, is used in enormous quantities not for people's consumption, but as cattle feed; it is transformed into high-energy, expensive protein. Beef produced in this way costs the world 100 times as much energy, labour and money as does the equivalent amount of wheat, and is available to a small minority of the world's population. Flowers and tomatoes are grown in Colombia for direct export to the USA. Cocoa and coffee are grown in Ghana and the Ivory Coast specifically for export to Europe. Many countries now have virtually one-crop economies - based on, for instance, sugar, cotton, coffee, or groundnuts - which means they have to import quantities of staple foods to feed their populations. Prices for these staples are set by world commodity markets. Increases in these prices mean such countries have to export more and more of their own crops in order to assure the same quantity of food for their people. Imports from western countries also include expensive highly processed foods such as coca-cola, baby milk powder, canned beans and even bread. These products usually have a detrimental effect on people's nutrition both because they are less nourishing than locally-produced food, and also because they are much more expensive. In addition, local foods are often considered inferior. One good example of this is breastmilk. Imports of canned baby mi^c powder and the image of the "bouncy bottle-fed" child (amongst other things) have led to the belief that bottlefeeding is superior, thus denying children the most valuable (and indigenous) form of nourishment available in the crucial beginning years.
In industrialised countries, women have long since lost control over land, which is mostly farmed with a minimum of labourers and a maximum of machinery, fertilizers and"pesticides. Instead they have the edifying task of going to the store to choose among the various pre-packaged, pre-prepared, industrially processed foods on the shelves. Many such processed foods have had so many of the natural nutrients taken out of them that these elements have to be put back again artificially, warranting the claim "enriched". Others have become so worthless that a vital part of one's diet consists of bottled vitamin and mineral tablets, also marketed in impressive quantities in the drug store. Finding food which has not been chemically tampered with becomes a major task, and the rise of the "health food store" as a speciality is a good comment on how most food is no longer inherently nutritious or health-giving. There is not necessarily a relationship between affluence and health. "Mal"-nutrition also exists in richer countries where overconsumption can lead to heart diseases, obesity, colon cancer etc.
Education of women and men about food values is only one small aspect of the question of health and nutrition. What is needed is a recognition of the total role that women play in food production, handling, processing, preparing and marketing, and of the broader socio-political issues which affect these processes.
Provision of water is another process in which women are intimately involved. In most developing countries women provide water for the household, often walking long distances and carrying heavy loads of water. This in itself has a detrimental effect of their health - fatigue and backache. "In addition, in many places women spend more time actually working in the water - washing clothes, for instance — and so may be more often exposed to the water-borne diseases."^^ (The waterborne diseases are: diarrhea, polio, typhoid, schistosomiasis, river blindness, malaria.) Because it is women's task, the provision of water is undervalued. Thus technology to alleviate this task is lacking and insufficient efforts are made to provide communities with safe and convenient sources of water.
overwork
Perhaps one of the least considered factors affecting women's health is overwork. The back-breaking tasks of fetching water and subsistance farming done by rural women in developing countries (and examined in more detail in the chapter on Rural Development) is only one side of the coin. Women everywhere have inferior status, so that education and employment opportunities lead them into low-paid arduous jobs such as working on an assembly line for electronics companies, as check-out counter clerks in big supermarkets, as domestic workers and as prostitutes, in all countries of the world it is women who have major responsibility for childcare and housekeeping and for most women this means a double or triple workload with outside employment too.
This can only have a long-term detrimental effect on women's health: fatigue, mental and physical stress, incurring increased susceptibility to infection.
women-oriented health/action
Issues which are fundamental to women and their health are: nutrition, sanitation, infections, stress, overwork, work hazards, drugs, contraception, pregnancy and childbirth, and sexuality. All these aspects are rooted in the fact that women are regarded as second-class citizens whose roles are diminished and downgraded in nearly all societies. Women are and have always been providers of health care, yet they have little or no control over the shaping of health services, research, the environment or the work they do.
The women's health movement, grown up over the past two decades, has now become one of the strongest elements of the women's movement internationally. In June 1981 the Third International Women and Health Meeting took place in Geneva, Switzerland, bringing together 500 women from 35 countries of the world. Organised by ISIS and the Women's Health Centre in Geneva, the meeting was remarkable for the exchange that took place: regardless of country, continent or socio-economic status, women found that they face very similar problems: everywhere they are subject to laws, customs and mental attitudes which institutionalize their supposed inferiority. Whether it is forced sterilization as in Puerto Rico, or the denial of sterilization to women who want it, as in France, whether one considers "family planning" centres in India or the increasingly restricted availability of abortion in the USA, the result is the same: women do not have the right or possibility to control their own bodies.
The Geneva meeting was important in contributing towards a feminist analysis of women and health, and in providing information about women's action. The summaries and recommendations below are based on the reports from the meeting (cf. ISIS International Bulletin no. 20,1981).
health systems and services
Large, complex health services with expensive hospitals and technologies and highly qualified doctors are not only inappropriate for providing health care but do not reach most people in the world. Paramedical workers — a vast majority of whom are women — are crucial in providing basic health services. In developing countries they have a much more important role than paramedics in industrialized countries. In the latter, the hierarchy is more rigid and dominated by the medical system which limits paramedics' freedom of action even though it is they who are in continual contact with the patients and who do the work — giving medical care as well as psychological support. A report from Bangladesh sums up this situation:
When a paramedic goes to the village during the day, there are mostly women at home. All the men work in the daytime. In Bangladesh the women are often shy in front of men. They are afraid to let a strange man into their house. They are even more afraid if a male doctor must touch them. It is best, then, if paramedics are women. At Gonoshasthaya Kendra, sixty percent of the paramedics are women... The women paramedics of Savar do tubectomy surgery, go to the village on bicycles, keep statistics, cure patients, give the pill, injections and do pathology work. Everything depends upon the application of real education and simple, comprehensible training.23
Recognition of women's major role in this respect, plus simple, comprehensible training designed and given by women, are fundamental to improving women's - and everyone's health.
methods of healing
Many of the drugs currently marketed all over the world are expensive, inadequate, dangerous or inappropriate to answer people's health needs. In fact a very limited number of these drugs is necessary to treat diseases (vaccines, antibiotics, anti infectious drugs, pain-killers, disinfectants and skin preparations). The prestige of western medicine and the cult of pill popping as a "solution" to anything from fatigue to diarrhea have clouded the real reasons for ill-health, and have frequently obscured or taken over from indigenous methods of healing. Other methods of healing have existed for centuries and are much cheaper, more available to people than chemically-based drugs which must be manufactured, distributed and paid for, often in foreign currency.
In the West, the women's health movement is researching and using these methods: homeopathy (treating likes by likes the treatment of the whole person with medicines prepared from plants, minerals and animal tissue diluted and dynamised, whose curative power is also the disease-producing power); acupuncture and acupressure (on the principle of restoring the natural balance and harmony within the human system); herbal medicine (based on plants) and nutrition. At the Geneva meeting women from developing and industrialized countries shared their knowledge and experience in these methods and spoke of how this will be lost unless we can document and reinforce these methods.
There is an urgent need for women to document and share knowledge and experiences of "soft" healing methods. This will give more power and control to women over their own and their families' health needs. It is particularly important that pharmaceutical companies do not take over this domain by expropriating plants, patenting them, then selling them as any other drug at exorbitant prices.
reproduction and sexuality
An international network for women to share information about all aspects of contraception already exists (ICASC — International Contraception, Abortion and Sterilization Campaign, see below). This is an important step in understanding the issues involved and the powers which control and influence women. Women at the Geneva meeting had much to say on all these issues, including the following:
We demand that abortion be made safe, legal and available in all countries of the world and that it be done in a dignified, comfortable, non-judgmental atmosphere so that women everywhere will be able to control their reproductive lives and make choices about their own bodies.
Experimentation: there are two types, the first, women on women - using natural methods as well as barriers. The second is widespread experimentation on whole populations. We must take a stand against this widespread experimentation.
Solutions: we must find solutions for women in all parts of the world and we can only do that through better research programmes.24
In this context the meeting frequently emphasized the need for contraceptive research to be not only women-oriented but conducted and controlled by women. Only then can solutions which do not hurt women be found.
Emphasis on women-oriented childbirth must be encouraged against the tide of technological interventions. Traditional birth attendants, village midwives, etc. must be supported and given training in infection-preventing techniques.
Information about all aspects of sexuality is vital to women everywhere, especially to eliminate taboos and practices such as genital mutilation. Again the sharing of information prepared by women has been a major part of the women's health movement and the fact that a book like Our Bodies Ourselves (see resources) has been translated into fourteen languages selling several million copies is testimony to the need for such information.
Not all women are heterosexual and the assumption that they are must be changed. Non-discriminatory practices and information about lesbianism are equally important.
Sex education for both women and men will help them determine the use of their sexuality and reproductive rights. A document from the National Council of Women of Kenya says:
We see it as a matter of urgency that widespread educational seminars be organised, aimed at Kenya's adult male population. The educated youth in Kenya do not need to be persuaded as to the merits or the necessity of Family Planning. We must ensure, however, that the prejudice of the fathers, based on ignorance, do not get transmitted into the children. The fathers must be educated. It is also very important for us to realize that the majority of women in this country do not make the decisions or are not in a position to do so. In many instances, they will go by what their husbands say or think. We, see it as crucial that men are educated on this subject. We should also consider the publication of Family Planning Education materials that are aimed specifically at the male population.25
nutrition
Since women are responsible for it, infant nutrition is always stressed. It is not difficult to realize that breastfeeding is the best way to feed infants from birth to at least six months. Breast milk has all the vital nutrients for beginning human development and for the child to grow into a healthy person. It also gives vital immunities which protect against infection.
Many factors make breast feeding difficult for women all over the world. Women at the Geneva meeting were clear in their statements:
As women we cannot simply be "in favour of breast feeding in a vacuum. We have to fight especially on the question of material conditions everywhere in the world — adequate income, maternity leave, housing, food and the importance given to having children in optimum conditions. The idyllic description frequently given of the joys and advantages of breast feeding are not in themselves, meaningful to us without all the other conditions fulfilled.26
Women need appropriate technology to help them in their work of food production, processing and preparation and for water collection and treatment. This technology must be designed and developed by women for it to be "appropriate".
Since pregnancy, childbirth and breastfeeding are a drain on women nutritionally, contraception and child spacing play an important role in women's nutrition and thus their total health. But again, population control activities which employ techniques of mass introduction of (harmful) contraceptives, sterilization etc. without valid informed consent, must be stopped. Research in this area must be controlled and carried out by women.
work
Overwork, stress and strain, sexual harrassment, hazards at the workplace, and violence, all affect women's health adversely. They all have their source in the sexist nature of society whereby women are undervalued and discriminated against at every turn, or simply regarded as sex objects. The profound and fundamental changes which are needed to break this situation encompass much more than issues of health. Probably as with every other area - women will simply have to fight at many levels for even small changes to occur. The publication of this book is one contribution to that process.
Footnotes
1 Earthscan, "Primary Health Care," Press Briefing Document, no. 9, September 1978, p. 25.
2 Dianna Melrose, The Great Health Robbery (Oxford: Oxfam, 1981), p. 10.
3 Haslemere Group, Who Needs the Drug Companies? (London: 1976), p. 4.
4 Les Femmes du Groupe de Travail Seveso, Seveso est Partout (Geneva: 1976).
5 Health for the Millions, vol. 7 nos. 2 & 3, April-June 1981, p. 9.
6 Ibid, p. 14.
7 Concerned Rush Students, A Critical Look at the Drug Industry: How Profit Distorts Medicine (Chicago: 1977), part 6, p. 4.
8 Health for the Millions, vol. 7 nos. 2 & 3, April-June 1981, p. 19.
9 Gonoshasthaya Kendra Progress Report, no. 7, August 1980, p. 44.
10 Health for the Millions, vol. 7 nos. 2 & 3, April-June 1981, p. 14.
11 Barbara Ehrenreich and Deirdre English, Witches Midwives and Nurses (New York: The Feminist Press, 1973), p. 1.
12 Malcolm Segall, "The Politics of Health in Tanzania," Development and Change, vol. 4 no. 1, 1972-3.
13 Earthscan, "Primary Health Care," p. 7.
14 Ibid, p. 5.
15 Marit Kromberg, "New Music, Old Harmony," Development Forum, June 1978, p. 6.
16 Padma Prakash, Women and Health: Health Issues in the Context of the Women's Movement in India (Bombay: 1980), p. 5.
17 Quoted in Patricia Blair, Programming for Women and Health (Washington: Equity Policy Center, 1980), p. 40.
18 UNFPA, What it is. What it does (New York, no date).
19 "Rethinking Food and Nutrition Education," Food and Nutrition Bulletin, vol. 2 no. 2, 1980, p. 23.
20 Protein-Calorie Advisory Group of the United Nations, Women in Food Production, Food Handling and Nutrition (New York: 1977), section 3, p. 2.
21 Kamala JayaRao, "Who is Malnourished: Mother or the Woman?" Medico Friend Circle Bulletin, no. 50, 1980, p. 1.
22 Unicef Office for Europe, Women, Health and Development (Geneva: 1981) section 2, p. 28.
23 Gita Chakravarty, Case Study (Dacca: Gonoshasthaya Kendra, 1978), p. 2.
24 ISIS International Bulletin, no. 20, 1981, pp. 8 and 10.
25 Kenya Woman, vol. 1 no. 6, 1978.
26 ISIS no. 20, p. 13.