Gender, Development, and Health / Edition 1

by Caroline Sweetman

Overview

What are the differences between women’s and men’s experiences of health, sickness and health care? How does our gender identity affect our physical and mental wellbeing? Despite improvements in health indicators in many countries, developing countries are currently facing a health crisis. New diseases like HIV and drug-resistant strains of diseases including malaria, pneumonia and tuberculosis, are spreading. Many people in developing countries have never had access to formal medical services. Others have lost their access due to reductions in public spending as a result of structural adjustment policies, international debt repayments and the de-prioritisation of health against other sectors. This book argues that two fundamental changes are needed if both women and men are to achieve better health. The first of these is to ensure equal access to all the resources that men and women need for healthy minds and bodies: not only to medical care, but to food, water, shelter, a source of income and a sense of control over ones life. The second is to ensure that health services and resources enable women and men to meet all their physical and mental health needs. Articles included here focus on understandings of reproductive health; integrating gender issues into infectious disease prevention; the impact of HIV/AIDS on women; working with communities to promote health and on the monitoring and evaluation of health projects from a gender perspective.

Product Details

ISBN-13:	9780855984564
Publisher:	Oxfam Publishing
Publication date:	09/28/2001
Series:	Oxfam Focus on Gender Series
Edition description:	New Edition
Pages:	116
Product dimensions:	7.50(w) x 9.75(h) x 0.32(d)

About the Author

Caroline Sweetman is Editor of the international journal Gender and Development.

Read an Excerpt

CHAPTER 1

The reproductive health of refugees: lessons beyond ICPD

Colette Harris and Ines Smyth

The vulnerability of populations affected by conflict or environmental disasters was stressed at the International Conference on Population and Development (ICPD) held in Cairo in 1994. In particular, the high mortality and morbidity rates among refugees were emphasised. The ICPD and its Programme of Action have enabled a degree of consensus to be reached on the importance of reproductive health and rights, including those of refugees and internally displaced people. Post-Cairo, some of the language and concerns of the ICPD Programme of Action are being brought into the initiatives of international agencies, including UN agencies and international NGOs. Reproductive health policies and programmes have started to be implemented in refugee communities, and service-delivery has begun to be systematised. However, if the mistakes and abuses of past family-planning programmes are to be avoided, we need to integrate some critical insights from feminists working in the fields of health and anthropology. However, there are structural constraints within relief organisations and operations which need to be overcome if they are to benefit from such insights.

Refugees are, by definition, survivors, who use their personal and material resources to escape danger, persecution, and fear. They are also very vulnerable to threats to their physical well-being and identity, as well as to threats to their survival as a group (based on ethnic, religious, or other grounds). Their vulnerability needs to be understood in the context of the increase in global economic, social, and environmental insecurity over recent decades (Baud and Smyth 1997). The key elements of this 'new world disorder' are armed conflict, military actions, and the disappearance of old State structures, all of which have profound implications for biological reproduction (Pearson 1997,12).

Data concerning the numbers of refugees in the world are notoriously unreliable. What is certain is that their numbers are on the increase. In the last few years, there has been an escalation in the numbers of those displaced by conflicts and by major natural disasters, as well as those forced to move by deliberate government policies. The International Federation of Red Cross and Red Crescent Societies (1995) reports that in 1985 there were 22 million refugees and internally displaced people, and that by 1995 their number had increased to 37 million. In 1998 alone, well over a million people in Central America, Bangladesh, Central Asia, and parts of Africa lost their homes in floods. Large numbers of refugees from Kosovo and East Timor have moved to neighbouring countries under extremely difficult conditions. It is impossible to assess how many of these people will be able to rebuild their homes and communities in the near future, and how many will continue to rely on relief agencies for help. Very long-term refugee camps now exist in a number of countries. There are also large numbers of people who have been displaced, but remain within the borders of their country of origin – at least 24 million, according to one estimate (Wulf 1994). Internally displaced people often flee their homes for the same reasons, and in the same circumstances, as those who have crossed national boundaries. However, the distinction in terminology means that they receive little recognition and help at international level, and thus, at times, may be substantially worse off than refugees who have left their country of origin.

The care of these refugee populations presents considerable challenges arising from the circumstances of extreme poverty, destitution, and insecurity in which most have to live, and the large numbers involved. They exist in a political vacuum, outside the 'normal' life of any country, stripped of political rights, and alienated from viable economic opportunities and from access to social provisioning. For large numbers of refugees, virtually the only services available – including health care – are those supplied by aid organisations. This applies not only to the first stages of emergency evacuation, but also to the succeeding stages which may continue, as has been noted above, for a very long time. Displacement is often considered a temporary situation, and the long-term solution is supposed to be repatriation to the place of origin or as near to it as possible. While a 'voluntary, safe return to their own countries' (Keen 1992) may well be the best solution to the refugees' problems, it is not always possible. Refugees represent a new type of population, rather than a temporary condition.

Refugees' health needs

The psychological and physical conditions in which refugees live may mean that they have greater need for health care and good nourishment than other citizens – either of the country of origin, or the host country. At present, the provision of health care for refugees is a long way from being adequate, and this is especially true with regard to reproductive health services. Women and children comprise a large proportion of the refugee and displaced population, at least in some contexts, and are sections of the populations with the largest health care needs.

Owing to the fact that interest in the reproductive health and rights of refugees is relatively recent, and the difficulties of carrying out studies at field level in certain situations, there is comparatively little research and information on the reproductive health status and needs of refugee women and men. It is often stated that at least 75 per cent of the world's refugee and displaced people are women and girls (Bandarage 1997), and that of these, 20 per cent are of reproductive age and 25 per cent are expectant mothers (Davidson 1995). The reproductive-health risks to which they are exposed are well known, but accurate information on the consequences is lacking. However, an impression can be gained from indirect statistical data. For example, maternal mortality in the countries between which refugees mostly move is up to 200 times higher than in Western nations (Poore 1995). Anecdotal evidence is sometimes used to claim very high fertility for women in refugee populations, but hard evidence for such a conclusion is often absent.

Whatever the statistics concerning the proportion of women among refugees, the conditions under which flight and resettlement take place hold greater dangers for women because of their disadvantaged position in gender relations, and their role in biological reproduction. Their ability to conceive, carry successful pregnancies to term and give birth to healthy babies, as well as their capacity to have sexual relations and lead reproductive lives free of violence and abuse, may all be affected. The situation may be further exacerbated by the breakdown of kinship ties or community networks on which women commonly rely during and after childbirth, or in times of illness. Similarly, women's traditional resources for contraception, abortion, and the like may be lost to them. Moreover, such situations are often marked by violence against women, including rape and forced sex in order to gain access to protection or the means of survival for themselves and their dependants. The possible consequences of sexually transmitted diseases and dangerous pregnancies are grave.

Lessons from Cairo and beyond

For several decades, feminists and other advocates working in the field of health and women's rights have been discussing issues related to reproductive health. The result has been a body of literature which has rehearsed many of the practical, theoretical, ethical, and political dilemmas concerning reproductive health.

This body of literature can be divided into two related categories, both of which could be of great use in developing health policies which take into account the specific circumstances of refugees, especially women. The first category comes out of the work of the international health movement, and is directly related to aspects of reproductive health. The second has emerged from the discipline of anthropology and, to a lesser extent, sociology. It is related to issues of cultural specificity and ways of working with local populations, and is not necessarily directly related to questions of reproductive health.

Feminist insights into reproductive health

As stated at the start of this article, the Plan of Action of the ICPD has provided a major impetus to interest in the reproductive health of refugees, and is also the source of the basic principles that are supposed to guide the provision of services. It is unanimously recognised that many of the positions taken by the Plan of Action are the result of the long-term influence of the work of feminist activists, academics, and health workers (Lassonde 1997).

A broader understanding of reproductive health

Among the most fundamental critical insights from feminist health advocates has been that reproductive rights are not limited to birth control, or to birth control plus mother-and-child health, sexually transmitted diseases, and HIV/AIDS. The concept encompasses many other aspects of health and well-being, including abortion rights, gynaecological health (including menstruation), issues of infertility (which may be a greater problem for some populations than the need for birth control), and sexual health (as well as violence). This expansion of the notion of reproductive health is a direct consequence of the critical stance that feminist and other health advocates have long taken in relation to population-control programmes (Garcia Moreno and Claro 1994). Such programmes, they maintain, have focused on fertility reduction as the solution to what policy-makers perceive as the most pressing global problem: that of population growth, especially among the poor in developing countries. Sometimes they have added a concern for the containment of the growing pandemic of AIDS. Both these concerns have lent themselves to coercive treatment of populations (Hartmann 1987).

Another essential critique put forward by feminists is that reproductive health cannot be addressed merely as a medical matter. It cannot be separated from the conditions of poverty and insecurity in which many men and women in developing countries live. Such conditions often dictate reproductive and fertility behaviour, but they also determine access to adequate nutrition, sanitation, and health services. This understanding also helps to locate broader population issues in the context of economic growth and development. '... The population issue must be defined as the right to determine and make reproductive decisions in the context of fulfilling secure livelihoods, basic needs (including reproductive health) and political participation.' (Sen 1994)

Also central to feminist analysis is the idea that problems of reproductive health are related to gender-based power relations, which systematically disadvantage women and girls. This idea has several components. One is that, in most societies, women gain social status and position through their reproductive functions, so that their reproductive health has considerable repercussions for their overall existence (Gupta 1996). At the same time, many women in different locations enjoy little control over their reproductive behaviour and its outcome. In fact, women's sexuality and procreative functions are generally at the centre of far-reaching cultural norms. As a consequence, in many societies decisions about whether and when women should marry, with whom, when they should have sexual relations, and when and how many children they have, are controlled by spouses, other senior household members (for example, mothers-in-law), religious leaders, and policymakers (Berer 1994). In particular, unmarried adolescent girls tend to be the focus of strict controls to guarantee not merely their virginity, but also a spotless reputation.

The emphasis of feminist health advocates on women and their reproductive health and rights does not mean that women are the only focus in these debates. It has been recognised for some time that men and adolescents of both sexes also have reproductive needs. Furthermore, these issues are not only the concern of people of reproductive age. Both older men, and post-menopausal women, have reproductive-health needs which should be acknowledged and taken into consideration.

Birth control and other medical provisions

Many of the relevant debates have concentrated largely on issues of birth control/family planning, as these were the major focus of the international community in the pre-Cairo era. Many studies have recorded the abusive character of fertility-control programmes (Dixon-Mueller 1993). Women in general, as well as minority groups under-represented in governments, have all too often been targeted for specific fertility-reduction programmes, including forced sterilisation (Hartmann 1987). At the same time, large numbers of people who might wish to use modern contraception do not have adequate access to affordable methods of their choice.

Coercive programmes have been shown to be very often ineffective, and even counterproductive. Research has indicated that countries such as India with the strongest population policies are not necessarily those that show the greatest reduction in fertility. Also, couples using modern methods of contraception do not necessarily have fewer children than those using traditional methods such as abstinence and breast-feeding (for example, Pearce 1995). The abusive practices of population-control policies have often made women less willing to use contraceptives (Ravindran 1993; Hartmann 1993). Therefore, groups of people who have been targeted by very strong population control programmes may be especially wary of contact with modern medicine and its practitioners, including modern methods of birth control.

The technology of these methods has also been a topic for considerably heated debate, particularly on the problems associated with hormonal and with provider-dependent long-acting contraceptives such as Norplant, Depo Provera and, more recently, vaccines (Hardon and Hayes 1998). The latter are attractive to international health-service providers and governments, since they have properties of effectiveness and ease of delivery (Sen and Snow 1994). On the other hand, many women have experienced negative side effects from long-acting hormonal contraceptives, including increased bleeding, headaches, weight-loss or gain, and even infertility (Panos 1994). Barrier methods, especially the female condom and the diaphragm, are insufficiently available, in great part because Western providers believe them to be unacceptable to local populations and also because they do not consider them effective enough (although HIV/AIDS has led to a re-evaluation of this position).

An important aspect of these debates, and the area in which there has been the most consensus, is the need to provide high-quality reproductive-health programmes. Since Cairo, the idea that these should not be limited to family planning but should instead include a wide range of reproductive health services is gradually becoming accepted. Furthermore, in relation to such services the concept of quality of care is often mentioned. This encompasses various components, the most important of which are choice of method; technical competence and good interpersonal skills of providers; full and informed consent in the choice of contraceptives; and appropriate constellations of services including mechanisms for follow-up (Bruce 1990).

(Continues…)

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Table of Contents

Editorial Caroline Sweetman, 2,
The reproductive health of refugees: lessons beyond ICPD Colette Harris and Ines Smyth, 10,
The meaning of reproductive health for developing countries: the case of the Middle East Huda Zurayk, 22,
Environment, living spaces, and health: compound-organisation practices in a Bamako squatter settlement, Mali Paule Simard and Maria De Koninck, 28,
Safe motherhood in the time of AIDS: the illusion of reproductive 'choice' Carolyn Baylies, 40,
Danger and opportunity: responding to HIV with vision Kate Butcher and Alice Welbourn, 51,
Strengthening grandmother networks to improve community nutrition: experience from Senegal Judi Aubel, Ibrahima Touré, Mamadou Diagne, Kalala Lazin, El Hadj Alioune Sène, Yirime Faye, and Mouhamadou Tandia, 62,
Teaching about gender, health, and communicable disease: experiences and challenges Rachel Tolhurst and Sally Theobald, 74,
Attitudes towards abortion among medical trainees in Mexico City public hospitals Deyanira González de León Aguirre and Deborah L. Billings, 87,
Enhancing gender equity in health programmes: monitoring and evaluation Mohga Kamal Smith, 95,
Resources Compiled by Erin Murphy Graham, 106,
Publications, 106,
Organisations, 112,
Electronic Resources, 113,
Videos, 114,
Courses, 115,