“My heart can’t be cured, because I’m too poor to pay my son’s school tuition — and that is breaking my heart” (Korean village woman)
How can you spot a woman health activist in a crowd? She has a nagging cough, and there are dark circles under her eyes from a lack of sleep. Her feet drag as she limps into a UN meeting on women’s health. For a feminist with a cause, poor health can be an unwelcome but persistent companion that reminds her that there is a price to pay for activism at the UN. During the COVID-19 pandemic, women at the frontlines and in the home often pay a high price for their own well-being.
None of this should dissuade women from joining the political fray. If we want to accomplish anything, we must have sound bodies and minds to be successful. Yet, too often, we put our own health in jeopardy, and that is a mistake. Complete well-being – mental, physical and social – is the foundation for personal, economic, and political success.
Women have a very steep mountain to climb as health activists. Here are some of the major challenges women are facing:
- The World Health Organization reports that female genital mutilation, which increases the chances of poor physical and mental health in later years, affects three million girls every year.
- Although maternal mortality has steadily declined in the past decade, mothers who suffer the most are without access to universal healthcare and face discrimination based on ethnicity, race, geography, and/or religion.
- Teenage girls are exposed prematurely to sexually transmitted diseases, unsafe motherhood, and abortions. They are particularly affected by iron-deficiency anemia.
- Violence against women results in physical and mental illnesses that often go untreated. In the United States, a woman is assaulted every fifteen seconds. Refugee women experience mental trauma when they are raped or forced to have children.
- Older women who are heads of household suffer from poor nutrition, lack of health services, and disability related to lifelong deprivation and poverty.
What have governments done to protect the health of women and girls?
Women’s health was securely established at the UN as a human right. The definition of women’s health included the highly controversial issue of women’s right to sexual and reproductive health. The Beijing Platform for Action states: “The human rights of women include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence.” These are critically important thoughts. For the first time in intergovernmental negotiations, the right to decide what one does with one’s own body and sexuality was understood as a human right that deserved protection by the state.
Women’s health is also increasingly recognized as more than a purely medical issue. As the sustainable development goals assert, women’s health is dependent on the progress of other areas of social development, such as legal equality, economic development, and personal security. Better access to quality health services is an absolute prerequisite for the good health of women and girls. To help achieve this, improvements in girls’ education, women’s economic status and the environment are essential. For example, there is a correlation between women’s improved education and lowered infant mortality rates. Oftentimes, the more education a woman receives, the better paying her job is and the more say she has about how to use her income. All of these benefits are better resources to keep her healthy.
Above all, women leaders, male government officials, and youth groups are starting to become active in the health realm, rather than depending solely on medical specialists to make plans. The responsibility for women’s health should not be left to a handful of medical elites. Most developing countries – and even industrialized ones – view self-care and traditional healers and medicine as important in health systems as allopathic medicine.
It is almost a cliché now that women’s leadership is a human resource that can help sustainable economic development achieve its goals. However, the truth is that women’s health has to come first. To strengthen the health of others, the women’s movement needs to protect one of its most prized possession: the well-being of its leaders. The next time we feel like the world is about to cave in and are too exhausted to hold it up, just remember that we are only supposed to hold up half the sky. There is no shame in asking men to hold up the other half.
A village woman from Tamil Nadu, India, packed her bag and checked to make sure that she had enough money to pay the doctor. She would take the bus to a faraway city clinic for an amniocentesis test. She had become pregnant for the third time, and her husband’s family told her that she must have a boy. She prayed to the gods, took herbal baths, and did almost everything the old women told her to do — all without success. If the test showed that she was having a girl, she would have an abortion at the risk of her own health. The family simply couldn’t afford to have any more daughters: more girls, more dowries.
I repeat this story as often as I can, because it highlights how abuses of medical technology can perpetuate gender discrimination even before birth. This happens all too often in countries where amniocentesis is used for sex selection.
Technology itself is likely not the source of the problem. The problem is the varied ways that both clients and practitioners use technology. When I had an amniocentesis in a New York hospital, it provided very useful information. Amniocentesis samples amniotic fluid in order to detect genetic problems in high-risk pregnancies. In my case, doctors confirmed that the fetus was not likely to develop a crippling birth defect such as spina bifida. That was very reassuring news.
Accounts abound about the questionable use of this important medical procedure, but few efforts by governments have worked successfully. Raising awareness around this topic is a useful first step, but it probably is not enough. We must address the root of the problem: the socioeconomic complexities of marriage. Women may want daughters, but their personal preference may have to take a back seat in favor of their family’s welfare. People are concerned about expensive dowries. Daughters may leave forever and take the family’s wealth with them. On the other hand, inheritance laws mean that boys are more likely to live at home after marriage and provide social security to parents in their old age. Such arguments could eventually shake the determination of the most caring parents.
Fortunately, for Indian women, the national government has tried to change health policies to avoid this abuse. But more effective, non-governmental organizations have taken up issues like amniocentesis with admirable respect for women who are most affected. Giving a voice to the women who are directly affected must be the starting point of reforms — not just the in the abuse of amniocentesis, but also the social and economic constraints on women. Their choices are the ones that really can make a difference.
The visit to the Tunisian mobile health clinic took us out of the city, past the Roman viaduct and towards the mountain villages. Tunis disappeared behind us on a winding upward road. Sparse settlements dotted the slopes, and draft animals wandered along the road. I spotted a girl on a donkey heading our way to the edge of the mountain village. Her water pails were slung on the donkey’s back. I thought, ‘That’s progress. Girls often have to walk while the boys get the rides.’ Crowds of Berber women, some wearing beautiful earrings and long skirts, bustled around a white truck, the mobile unit.
Children and some men sat nearby, watching us pull up. I was impressed to see the health clinic. Modern, spotlessly clean, and well equipped, the clinic was hard evidence that the government was serious about making contraceptives and reproductive health services accessible to everyone, even remote tribes. On this visit, I was particularly interested in the family planning policy and its emphasis on reaching men and boys. According to the director of the program, doctors had been much more successful in their efforts by orienting reproductive health services to both men and women . This was known as a couple’s approach.
I wanted to hear more from the men. I heard the inside story from the clinic’s physician. He was a young man who had left all of the trappings of a highly specialized career in order to complete a round of service to rural areas. When he talked about health services for men, he explained that this clinic wanted to start education efforts early reaching out to boys. However, that was one of the most difficult parts of his assignment. He established friendly relationships with girls, as they came in with their mothers since they were young and could count on seeing them as patients when they reached puberty. However, boys were different. They may tag along with their mothers as children. Yet, when they grew up, they shied away from his health center.
He initially thought that boys had no one to mentor them in the ways of life and did not confident in adult male family members. As a result, they experience the mysteries of changes in their bodies’ functions and appearances on their own or with their peers. The brave behavior stereotypically associated with boys failed when it came to mustering up the courage to walk into a reproductive health center. Few boys, if any, ever showed up. Yet, the doctor knew that the boys suffered from many disorders, including urinary tract infections and, occasionally, sexually transmitted diseases.
In most countries, the epidemiology of boys’ sexual and reproductive health problems is a mystery to health planners. The United Nations Population Fund which has championed women’s sexual and reproductive health and rights, is also a strong advocate of the same rights for men and boys. It recognizes that cultural traditions can have gender-specific effectives, often negative, on boy’s rights and freedoms. Boys, like girls, can grow up hidden behind a veil of social taboos. Even industrialized countries that pride themselves on modern approaches to youth problems have only begun to acknowledge that the health data on adolescent boys is dismal. With drugs, alcoholism, and teenage pregnancy at the top on the list of health priorities, boys’ sexual and reproductive health has fallen by the wayside, only to be picked up again when it’s too late.
Let’s remember that the availability of doctors doesn’t automatically mean that boys will consult them. A starting point for this issue would be counseling men who attend family planning clinics to learn more about their sons’ needs and advise health administrators on how to best adapt services. Progress has to start with an admission of ignorance. We cannot assume that backward traditions affect only girls. Sometimes, boys are also the losers.
If you are a dog-lover, you would be interested to know that tourists think of Geneva as one of the world’s most dog-friendly cities. This is not a trivial honor. In France and Switzerland, where dogs are pampered like children, a municipality’s attitude towards dogs can be considered a measure of its moral fiber. For some foreigners, Geneva appears to be a canine utopia where dogs are guaranteed first-class access to restaurants and public parks. Most owners can provide their loyal pets with basic needs, like housing with the amenities of warm beds and treats. Geneva citizens boast about their humane treatment of animals, but is their claim justified? I thought so until my recent visit to the city.
On the surface, things looked pretty good. Geneva offers better habitats for dogs than cities like Beirut or Bangkok. There is such disdain for dogs in the Islamic tradition that a Muslim’s worst insult would include comparisons to dogs in a string of profanities. In Bangkok, polluted waters and toxic dumps afflict many animals, so they have chronic skin sores. In those cities, a dog’s life is a wild and dangerous existence. Needless to say, people living in slums share their lot. Although Beijing and Seoul may offer strict ordinances to control pollution, I wouldn’t want to be a dog in either metropolis. Dogs are reportedly kidnapped, caged, fattened, then served up as dog soup.
On the other hand, Genevans put dogs in front of the plate, not on it. At the most elegant lakeside restaurants, dogs happily sniff the cordon bleu aromas while lingering under the tables. When dining at a famous bistro, I spied a large gold retriever strategically positioned among fellow beef lovers. Between pats on the head and admiring greetings from the waiters, she licked her paws and eyed her midnight snack. Swiss pets return the favor of their public privileges with characteristic national civility. I never saw a dog beg at another client’s table. Few things in Switzerland are enigmatic, but how pets abide by a code of good behavior is a true mystery.
Life for dogs is equally congenial at the Geneva Botanical Gardens. On a sunny spring Sunday, owners treat dogs to long walks along the lake. One day, I spotted a dachshund running about without his leash. No one seemed to think he was overstepping his boundaries when he ran off to greet other dogs. All pets without leashes were presumed to belong to someone, and I never saw a homeless dog wandering about. The owner would call out occasionally, and the dog would dutifully rejoined the family walk. (I observed that Swiss children behaved in a similar fashion).
My opinion of Genevans was increasingly favorable, and I was ready to give Geneva the Légion d’honneur medal for canine treatment when my Zimbabwean friend, Rudo Mungwashu, objected. She pointed out that since a large number of Swiss people are smokers, those with pets must subject them constantly to secondhand smoke. Dogs often frequent smoky bars and restaurants, so pregnant dogs and puppies must be also affected.
I had seen alarming evidence about secondhand smoke for humans. It increases children’s risk of middle ear infections, respiratory diseases, and asthma, and causes heart and lung diseases in women. The WHO report on gender, women and tobacco states that prolonged exposure to secondhand smoke can cause lung cancer and that women who live with partners who smoke may also be at great risk for heart disease. All of this is bad news for pregnant women, children, and pets who live with smokers. However, I had never seen any statistics on the impact of secondhand smoke on dogs. Animals were nonexistent on national health statistics, and exposure to secondhand smoke was an unknown — but possible — cause of canine death. Rudo had a point. As a true dog lover, I had to disqualify Geneva as a dog’s heaven.
One of my first UICEF assignments was in Burma (now Myanmar), where I evaluated the training of traditional birth attendants (TBAs). In the early 1980’s, Dr. Tin Tin Hmun, former director of maternal and child health for the Ministry of Health, was experimenting with blending traditional values and practices with modern medicine. When I arrived at a village health center, a dozen or so elderly woman were hovering around a paper cutout that was shaped like a woman’s womb. Beside this prop was a cloth doll. One of the women put her lips to the doll’s lips and started mouth-to-mouth resuscitation.
Dr. Hmun explained that this new skill was helping to save newborn lives and that TBAs were very willing to learn new techniques. She was able to work with her community, because she also respected older beliefs. None of the older women could read or write, but Dr. Hmun believed that they had extraordinary skills. Some of their techniques may have come from vast experience. We estimated that collectively in their lifetimes, the TBAs had delivered about 5,000 babies. The role of these elderly women extended beyond delivery; they were also advisors for prenatal and postnatal care and provided psycho-social support for mothers through the stressful post-partum period.
I asked one TBA what she used to do before she learned about reviving babies the modern way. “We used to take the placenta over to the open fire and fry it”, she explained. I asked if she thought that a fried placenta really helped newborns. She answered that she wasn’t sure, but it always encouraged mothers when someone was doing something. Now that a better and proven method was known, the TBA said that everyone agreed to do mouth-to-mouth resuscitation instead. On the other hand, there was one practice they wouldn’t give up: cutting the umbilical cord over a coin with a sharp piece of bamboo. “That brings good fortune,” said a TBA. However, to limit possible infections, Dr. Hmun instructed TBAs to sterilize the coin and bamboo along with cloths and other utensils.
In other countries, I have found rural women as traditional healers, herbalists, specialists of ancestral spiritual traditions, and traditional birth attendants. Even today, this elite corps of rural village women can be found practicing, oftentimes in cities. For that reason, I suggest that these rural village women are “medical women” in the broadest sense whose greatest asset often cannot be matched by modern doctors. These women are well-versed in traditional health culture and are locally available.
We have to add the local women to the ranks of rural women healthcare providers. Local women extend to mothers, mothers-in-law, and grandmothers. For example, in Korean villages, mothers-in-law were TBAs and expected to be called upon to bring a new life into this world. Mothers-in-laws in rural areas conducted rituals to ensure that ancestors came to help new parents and gave advice to young mothers about nutrition, such as avoiding certain foods like hot, spicy soups. In the post-partum period, these women also made sure that families observed the proper seclusion period, so “cold winds” would not enter a mother’s womb and make her sick.
Why do we still need to pay attention to rural women as part of the health care delivery system? The conventional argument is still valid: Women are the key decision-makers in family health. The majority of health decisions are made at this level. Rural women’s knowledge must be employed to ensure food security, good child nutrition, family use of water and sanitation, and environmental management. Modern medical practitioners must learn to speak in terms that rural women understand. If not, modern medicine will further lose the knowledge from rural women’s longstanding concepts of illness.
Poor women in cities as well as villages are the largest corps of unpaid, unappreciated, and unacknowledged healthcare providers. They must be recognized as a resource on socioeconomic development. If traditional birth attendants and other local healers can improve their skills and become successfully integrated into MCH programs, imagine how much richer our medical knowledge would be.
In the off-hours of Bangkok’s busy nightlife, massage parlor workers take off their number badges and step out of their fish tank-like windows where they sit waiting for customers to choose them. Dancers unhook themselves from ropes that support their athletic prances. They gather around steaming cups of tea and catch up on the latest television soap operas. While these daily routines restore a mood of normalcy to the intense, burned-out life of these young women, everyone is aware that nothing about this life is normal. Many of them must provide sexual services, as well as entertainment and massages. Since the AIDS epidemic hit Thailand in the 1980s, sex work has become a game of hide-and-seek with death.
Non-governmental organizations, government programs, and women’s groups have made sure that AIDs awareness has reached the entertainment business. Public health clinics have been set up in the midst of the neon-lit glimmer of the infamous Potpong tourist district. The clinics show videos for health education programs nonstop for patients in the waiting rooms. Women’s groups also established outposts in the same area. Activists are determined to raise the gender bias issues. They have highlighted the plight of child prostitutes, the near slave-like conditions of massage parlors, and the sexist bias of health programs. Their mission is urgent.
I ventured into Patpong with a government health worker. An elderly Chinese couple that owned the bar greeted us with a bow and told us that they hoped the AIDs scare was just a rumor. We told them that the situation was very critical and that their cooperation would be an important contribution to remedy the problem.
As the time approached for the health education session to begin, the bar girls came downstairs from their quarters. I quickly surveyed that their faces that were freshly scrubbed and had no makeup. Some looked like they were in their teens, although they probably had false identification cards. They chattered on like Bangkok swallows, pushing close to each other as they settled into the bar booths.
When the NGO nurse arrived, the noise subsided into an obedient silence, and the bar girls sat up attentively like students starting the day with their teacher. The lights dimmed, and the slide show began with hopeful musical messages about how sexually transmitted diseases are treatable and where to go for help. A somber tone quickly replaced the gay mood. The photos were unusually explicit, showing skin sores and the cancer-eaten flesh of AIDs patients. Some bar girls looked away. Everyone was pretty frightened by the end of the slide show.
The young women were very receptive to the main message of the day to use condoms. Heads bobbed in agreement. When the lights came up, the nurse took out her packets of condoms and did a perfect finger demonstration of how they slip on. Then, she offered one packet to each girl. One by one, they knelt in front of the nurse who assumed an air of a merciful angel. The bar girls received their gifts with their eyes to the ground and hands folded in respect.
Then, one young woman dared to ask, “How can we get men to wear these condoms? Do you have any suggestions?”
“You must tell men that they might get AIDs or other diseases if they don’t,” the nurse answered with an authoritative voice. That comment ended the friendly session, and everyone said farewell.
The leader of the group of girls, known as the “men’s favorite,” sat down with me and my translator. She assured me that the bar girls took these education messages seriously and were grateful that NGOs wanted to help. The only problem was that they could not make men put on condoms. They couldn’t explain this to the nurse and had learned to be realistic about the tourism business. “If we tell men that they will get AIDS, they won’t come back, and we will lose our jobs,” she aid.
I compared this situation with that of some European countries, where sex workers were mostly mature, assertive adults capable of organizing themselves into semi-unions. However, these bar girls had barely crossed the threshold from childhood to womanhood. From their perspective, the grand vision of the feminist movement about empowerment for young women seemed out of reach. In the eyes of Thai society, prostitutes are so-called “bad girls” who lived in a world of drugs and crime that was largely hidden from sight.
Nevertheless, a few women’s groups are working to shed light on an underground world of crime, kidnapping, and rape. Their actions are beginning to attract public attention. Prostitution is officially illegal, but enforcing the law is another matter. There are networks of sex slave traders who have cast their nets across Thailand’s hill tribes and poorer northern regions to entrap more girls. Some of the victims are as young as ten years old. The age slips lower as the AIDS epidemic progresses and the demand for virgins increases.
Feminists report the there are two underlying causes of prostitution: poverty and efficient sex trafficking organizations. Impoverished rural parents sell their daughters under the guise of paying a job broker as low as $200 to help girls find a job in a city. However, the broker is actually trafficking girls from rural villages to cities. Under changing hands many times, the victims may find themselves in tearooms as child prostitutes. Later, they are moved into the bars and massage parlors to service international tourists and businessmen.
Clients from Germany, France, and England have been lured by ads. One ad was posted by a Swiss travel group: “Slim, sun-burnt and sweet, [Thai prostitutes] love the white man in an erotic and devoted way. They are masters of the art of making love by nature, an art that we Europeans do not know.” Japanese, Chinese, Thai, and Arab businesses also entertain at establishments where customers can to step into rooms in the back for a little “special treatment.”
The tragedy of prostitution in many countries, such as the Philippines, Korea and Indonesia, is that the victims have often been blamed for the AIDS epidemic. Sex workers are portrayed as the new Typhoid Marys who carry the HIV virus. Health campaigns often focus exclusively on the health education, control, and surveillance of prostitutes, rather than that of their male clients. If this was not enough, improved surveillance among prostitutes has meant that those who contract the virus lose their jobs without health insurance or job compensation to cushion the financial blow.
It is time to stop blaming the victims. Women activists have called for more legal action and health education directed at the organizers of sex trafficking and male clients. More concerted action is needed, because the HIV/AIDS epidemic kills the most vulnerable women and girls. More women than men have AIDS worldwide, and UN AIDS reports that HIV prevalence among female sex workers ranged from 6.1 percent in Latin America to 36.9 percent in sub-Saharan Africa.
Let me end my story with a reminder of how rural poverty lies at the heart of the matter. Several months after my Patpong visit, I traveled to a poor northeast region near the Laotian border. I met a couple on their farm who were caring for a young child. They told me that she belonged to their daughter and that she did not have a father to take care of her. Then, they told me proudly of their beautiful daughter and how she left to find work in the city at a big restaurant. I asked the name of the restaurant, since I would go back to Bangkok and might take their greetings to her. They said that they didn’t know, but the job must have paid very well, since she sent money home every month. I looked at the child and remembered the bar girls in Patpong. I told the couple that perhaps I will meet their daughter in the city, but I did not say where it might be — in a restaurant, bar, or hospital for AIDS patients.
A slim boy hobbled on his lame leg to catch up with me. I turned to see a young face covered with dark lesions. The hot summer breeze lifted the smell of his tattered clothing into the air and followed him like a shadow. He had tattered bandages on his fingers that reminded me of Lazarus rising from the dead. A case of leprosy on two legs was heading toward me. I turned about and quickened my pace.
I wasn’t afraid of the boy. I had just spent a week at a leprosy center in Wardha, India. I knew that a leper’s casual touch never gave anyone else the disease. It took long and continual contact to transmit the disease. Then why did I instinctively turn away? I think it was the instinct to avoid any street beggar.
I thought that I’d hurry along to finish my errands. In New Delhi, if you start giving coins to a street beggar, you become surrounded by more. It was better to not get involved. My eyes spotted a taxi nearby. The boy called out in Hindi as if he had an emergency; he became more and more agitated. I worried that his keepers would beat him if he didn’t bring in money, so I stopped. When he reached me, he smiled and extended his thin arm to hand me something. It was my pen that I had dropped on the ground. Before I could thank him, he went off to join the lepers’ huddle against a dirt wall.
There was no medical reason this child should have had leprosy. The disease is curable. With the help of the World Health Organization, a treatment known as multidrug therapy (MDT) has reduced leprosy incidence by 85 percent. The achievement is not as well-heralded as it ought to be. If infected individuals go to a health clinic when they first notice the skin spots, they can be cured with MDT within six months. After the first dose, they are no longer infectious and can mingle in close contact with their family and friends. Early detection has probably prevented about one to two million people from becoming disabled. MDT is a miracle drug this boy should have had.
However, stigma and deformity have made access to MDT impossible. Many children do not have enough sensation in their limbs to avoid accidents that can lead to losing fingers and hands, such as burns. At the Wardha Center, founded by Mahatma Gandhi, artificial hands and legs were fashioned to help leprosy patients with their rehabilitation. With the help of education programs about the affliction in local communities, leprosy patients can marry and raise families. Their children do not inherit the disease. In some Indian areas where social awareness has been raised, leprosy patients have gotten jobs and have become productive members of their community.
Biomedical research has done its job by finding the miracle cure, but there is more work to be done. Continuing stigma prevents some doctors from specializing in leprosy, if not even learning about the disease. As a result, we have reached an impasse. MDT could help us eradicate the pockets of endemic leprosy in India, Nepal, and about 20 other countries. However, we must first decide that helping children with leprosy is a priority.
I lost the old pen. However, the boy gave me a very special gift to last a lifetime: A glimpse into a child’s innocence is as pure as their beginnings. His small gesture of forgiveness for my misunderstanding showed compassion beyond his years. Why is it so difficult for us to show that we care in return?
Mrs. Kim was a Korean traditional herbalist, the kind that people went to for every kind of ailment — mental, physical, social. Among the older village women, she did not stand out, dressed in puffy, loose pants that blew around her slim legs like noisy flags when she walked. Her hands had the firm clasp of someone used to gathering heavy firewood and pulling stubborn weeds out of gardens.
Her most valuable inheritance from her late husband was the knowledge of traditional medicine that she picked up as his lifelong assistant. When I met her, she was running a grocery store slash herbal shop to support her son, who had just finished his second year at Yonsei University. Villagers turned to her sage advice on treating arthritis, the common cold, and much more. If children were doing poorly in school, Mrs. Kim offered parents words of comfort and hints on how to motivate them. When babies refused to breastfeed, she visited the family and helped sooth tensions about who was to blame. If she couldn’t help patients with herbs, she made sure that they visited the local health clinic. In brief, she was a rural social worker, physical therapist, herbalist, and psychiatrist combined. I dubbed her the village social doctor, because she could cure many of the community’s social ills.
However, Mrs. Kim herself was ill. She had been in and out of the hospital for treatment of serious hypertension. When I asked about her health, she threw up her arms in exasperation. She said that many doctors had prescribed medicines, but not one had been successful. When she used herbal medicines and acupuncture, the symptoms just returned. She confided in me that after many months, she finally discovered the cause of her illness: her son’s school fees. Every year, a few months before his tuition was due, her condition would worsen. She would have trouble sleeping because of her worries. She also stopped paying for her own medication in order to save for her son’s needs.
“That is why modern medicine can’t cure me,” she explained. As long as she was poor and had to support her son, she didn’t think she would get better.
Too often, the relationship between poverty and health is reduced to simple solutions, like building another health clinic for the poor. If Mrs. Kim is to be truly cured, she must have access to anti-poverty programmes and subsidies for school fees as well as affordable medical services. When she recovered, she would have more money to invest in her son’s education.
At the household level, parents’ health and children’s education are intimately linked, and mothers are often the ones making the connections. If we improve women’s incomes and provide socioeconomic support, we will very likely raise the living standard of an entire family. At the meetings on the Sustainable Development Goals, we all must become the world’s social doctors focusing on social as well as physical and mental health.
Why are most Asian babies born with a birthmark that looks like a bruise at the base of the spine? Doctors and traditional midwives have different explanations for this Mongolian spot. According to medical experts, the bluish-grey blotch is a genetic gift from the parents that will gradually fade. However, if you ask a Korean rural villager about its origins, you might get a different answer. One old woman told me that babies need a little kick to help them come into this world. Life is so hard, and they don’t want to be born. A three-spirit deity of heaven, earth, and the underworld gives the baby a gentle push, leaving a tell-tale trace on the baby’s back.
In real life, traditional healers, such as three-spirit grandmothers, took charge of maternal and child healthcare once the baby was born. These traditional healers were the consultants on child nutrition, illness, and post-partum recovery for the first one hundred days of the baby’s life. They also performed rituals of prayer, food offers, and songs for ancestors to watch over the infant’s well-being.
Traditional, rural Korea is no exception. In many countries, the largest groups of healthcare providers in rural areas are women known as traditional birth attendants (TBAs) and female traditional healers. Village women often trust their strong moral character and years of experience — qualities that they say are sometimes missing among younger, modern doctors.
For decades, UN agencies, such as UNICEF and the UNFPA, regarded TBAs as invaluable human resources for providing health services, including immunization, family planning, and nutrition education. Training programs across the world were highly successful in mobilizing their support to reach women and help bridge the gap between modern and traditional health.
“We have sterilized birthing kits,” one healer explained to me, “but we also stick to our traditions, like cutting the umbilical cord on a coin so that the child will have good fortune. Doctors have taught us how to sterilize the coin and knife beforehand.”
Although TBAs and women healers participate in government-sponsored programs, few health policymakers are aware of the problems that these women face in carrying out their work. These women suffer from gender bias that keep them at the bottom of a health hierarchy, much like their counterparts in modern medicine. For example, in Korea, the herbalists and acupuncturists who dominate the upper levels of the traditional medical system are mostly men, many of whom are literate and practiced in cities. Below them were shamans, fortune-tellers, three-spirit grandmothers, and traditional midwives.
Female traditional healers are poor, illiterate, and landless heads of household. Their fees are typically lower than those of male specialists, so even after years of practice, they can still barely make ends meet. It is common for them to be paid in-kind. One shaman I knew usually received bags of rice, chickens, and clothing as payment. She never complained and always accepted whatever the patients could offer, because she felt that her mission in life was to serve everyone equally. However, there was never enough money to pay for many homeless friends who dropped in for a free meal or a quick loan.
Another obstacle that TBAs and women healers face is prejudice from doctors who believe these women discourage patients from using modern health services. While this has likely happened, the degree of competition is far less than one might expect. In Korea, Thailand, and Burkina Faso, I found that healers themselves often use modern medicine. For example, one traditional healer had facial cancer and was being treated in a high-tech cancer clinic. In her view, it was not a matter of modern versus traditional medicine, but rather how patients perceived their needs. Healers see themselves as helping to restore the will to live, because they typically deal with patients who are discouraged by ailments requiring long-term care, like tuberculosis and cancer. They also help patients survive depression and psycho-social complications after birthing that might interfere with effective treatment by modern physicians.
Much more anthropological research is needed on how medical pluralism affects women healers and their patients. Ultimately, the losers are the poor, many of whom are women, who go back and forth from one system to another, looking for someone who will treat the whole person — mind, body, heart, and soul.
When people ask me if the UN can make a difference, I think of one positive example. At the UN headquarters in New York, air pollution once afflicted many of us attending the Commission on the Status of Women (CSW) meetings. The source wasn’t noxious fumes from automobiles contaminating the indoor air. Rather, there were clouds of carcinogenic particles billowing over our heads and right under our noses in the Vienna Café. Cigarette smokers of all genders and nationalities were everywhere. If the World Health Organization had done an air pollution test, it would have clearly declared this area unfit to support life. Yet, in the 1990s, smoking was permitted in this public area.
I wasn’t so upset that women and men were indulging in cigarettes. After all, the sign posted near the trash only said that smoking was discouraged, not banned. I had more selfish notions in mind. Since I had kicked the habit years ago, I was determined to not let all the smoke tempt me. As it turned out, there was no escape.
Ironically, women’s health was a priority topic on that year’s CSW agenda. In a nearby conference room, the NGO Committee for the CSW on Mental Health was having intense discussions about women and substance abuse. I was listening to a doctor discuss drugs in the workplace when I got a distinct whiff of cigarette smoke. It had to be coming from the vents that circulate the air throughout the building. There was no way to open a window; there weren’t any. Anyone who has sat in a restaurant’s no smoking section knows how that feels. Air roams freely with total disregard for any signs and into every corner of a building.
“Why doesn’t the UN do something?” complained one NGO participant. “If the UN delegates don’t set an example, how can they expect the rest of the world to stop smoking?”
Someone defended the UN, noting that in many buildings, including the World Health Organization headquarters, smoking was banned. We were puzzled about where to submit an appeal, because no one knew who was responsible for the UN house rules. Whoever it was, they might consider that building workers and food servers could easily sue for prolonged exposure to air pollution if they developed respiratory diseases.
Passive smoke is no light matter. One study in the United States suggests that 37,000 deaths from cardiovascular diseases alone may be linked to inhaling smoke from other people’s cigarettes. Even more alarming, the risk of health damage for women and children appears to be greater than for men.
Everything else was going smoothly at the New York meeting, the tobacco problem aside. The Committee to Elimination all Forms of Discrimination Against Women (CEDAW) completed its elaboration on Article 12 concerning women’s health. It is implicitly understood that it is the duty of states to act swiftly and decisively to guarantee that women can exercise their human rights to health. These clarifications were then expressed to the CSW and discussed by a panel of experts. WHO representatives speaking for the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) took a bold stand in support of the women’s health movement and decried the tobacco companies’ aggressive campaigns to promote smoking. Women’s health was getting solid political support from all major groups, who were quickly becoming instant health experts.
We were still obliged to discuss our health priorities in the polluted environment of the UN Building. When I got home, I was reminded that there is another downside to smoking: the odor. My hair, papers, and clothing were all saturated with the smell of cigarettes. My daughter asked me suspiciously if I had been smoking. Having breathed the smoke-filled air at the UN for hours, I had to answer, “Yes.”
Today, this is no longer true. Smoking was finally prohibited at UN headquarters in 2008 through a resolution of the General Assembly.
The historic Beijing Platform for Action stated: “The human rights of women include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence…the ability of women to control their own fertility forms an important basis for the enjoyment of other rights.”
These statements were major victories for women’s human rights and empowerment, and the United States was one of the 189 governments that signed. However, the Platform’s opponents quickly moved to undercut its advances. The Helms Amendment, championed by the arch-conservative Jesse Helms, stated that American foreign aid could not be used to help pay for abortion services.
From the point of view of poor village women in Bangladesh, the United States may seem guilty of a double standard. While American women won the right to abortion in Roe V. Wade, the Helms Amendment sent the message that the United States didn’t support these same rights for others.
American foreign aid is a mere fraction of what American taxpayers spend abroad. Nevertheless, the US dollar carries great symbolic weight in poor countries plagued with famine and poverty. In rural Bangladesh, the impact of American policy on sexual and reproductive health is profound. One pilot-project area reported that an estimated one out of every five maternal deaths was due to complications from abortions. About 10,000 women in Bangladesh alone meet the same fate every year.
I learned of one of these cases during a visit to a rural health clinic. A woman named Rataner was left with two children after her husband died. She remarried but later discovered that her second spouse had other wives. Four and a half months pregnant, and without means to support her children, she obtained traditional herbs from her sister-in-law and used these to abort her fetus. The bleeding did not stop, and she fainted. Although she could have gotten medical attention in a distant hospital, she was never taken there. She died a few days later.
“Our hands are tied,” a project worker confided in me. “Women are dying from botched abortions, but we cannot provide the services for them. We need foreign help after all.” Unfortunately, many developing countries have no choice but to accept the conditions of those who offer support. Bangladesh’s family planning program is heavily dependent on American funds. One of the poorest countries in the world, Bangladesh has only a few hospital beds for every 100,000 people. Although its population growth rates are declining, Bangladesh faces a severe shortage of doctors, nurses, and health centers.
Unexpected pregnancies are a heavy burden for impoverished families on the brink of starvation. Another mouth to feed deprives the entire family of a chance to survive. Industrialization is also creating new social problems. Most of the women in Bangladesh must rely on a mix of modern and traditional forms of fertility regulation, both of which are highly unreliable. Rural women who start with oral contraceptives and become dissatisfied with its side effects often switch to something else or take the pill intermittently. If unwanted pregnancies occur—and modern health services can’t help—families turn to traditional health practitioners.
The impact of the Helms Amendment isn’t limited to sexual and reproductive health. It also inhibits AIDS prevention. Condoms are supposed to help prevent HIV/AIDs infections while safeguarding against unwanted pregnancies. However, they have a high failure rate. Unless safe abortions can be available on request, clients will be reluctant to use them.
How can American feminists help? They must become better informed about American aid policies affecting the sexual and reproductive rights of women abroad. Anti-abortion policies violate international agreements on women’s reproductive rights signed by the American government. A double-standard guiding American foreign aid not only hurts poor families, but also the government’s credibility even more.
When I was sick with hepatitis in New Delhi and faced with the possibility of being bedridden for days, I decided to find out what kind of doctors treated the lower castes and tribal peoples of India. I had heard that most modern doctors of high caste origins preferred practicing privately among the urban elites. By all traditional standards of caste purity, there was to be no symbolic or physical contact with untouchables. Even if the high-caste doctors were willing to cross caste lines, most untouchables and tribal peoples could not afford to pay their high fees.
“Biwani, I am not feeling very well and my stomach hurts. Can you ask your doctor to please come quickly?” I asked my friend’s Muslim house servant.
“Yes, saab (madame in Hindi),” he answered enthusiastically. “I know a good doctor. I will go to the market and get him right away.” I wondered what kind of doctor he could find in the market. My imagination conjured up images of untrustworthy quacks sitting in stalls, waiting like hawkers selling chickens for gullible patients. Would this market be equipped with dirty syringes and leftover antibiotics? Perhaps I had taken this experiment too far.
When Biwani returned, he was smiling triumphantly. A doctor was at his side, carrying an authoritative medical bag. My hopes rose. He looked like he might be licensed after all. In fact, he looked like a dentist I used to have as a child, the only one I would let drill my teeth.
I thought strange that although I knew nothing about him, his near-perfect English immediately inspired confidence in his medical qualifications. His questions were brief, and he narrowed the possibilities to one conclusion.
“You have a mild case of hepatitis,” he said. “As you know, you need plenty of rest. If you are interested in some modern Ayurvedic medicine, I can recommend Liv-52. You must try to eat more lentils and rice.”
I was anxious to find out how this refined, well-mannered doctor ended up treating peddlers and servants in the market rather than practicing in a hospital. He willingly told me his sad story. He was originally from a remote mountainous tribe. With the help of Christian missionaries, he was educated in the best schools and passed exams to study medicine. He completed his education, married a tribal woman, and looked forward to a happy medical career. He quickly learned that caste differences got in the way.
Few hospitals would hire him. His attempts at private practice failed as well. Hiding his tribal identity only worked for a while; eventually, someone would uncover his tribal status, and he would have to move on. Finally, he arrived at the New Delhi market where there were enough Muslims, tribal, and lower caste people who needed medical care. To his delight, foreigners like me sought his advice as well.
When he finished his story, I thought about India’s shortage of doctors. In the 1990s, less than 3 percent of the people of the hill tribes had access to modern medicine. Only one in one hundred thousand people in the whole country was treated by physicians in hospitals. In principle, educating more doctors and nurses would have helped remedy this situation.
However, the great experiment of equality through education faces many challenges. Unfortunately, for this doctor, educational achievement was not the gateway to equal opportunity. There is one real question that remains. Who is the real loser—the doctor, or the patient?
Times may be troubled, and sources of public revenue may be dwindling, but many experts say that investment in education and health resources is still the best way to strengthen a weak economy. I am a novice in international trade matters, but here is an idea that could improve workers’ productivity for generations to come. Solve this puzzle.
First Clue: This agricultural product is a legal, internationally traded commodity protected by the World Trade Organization (WTO) agreements. However, it has been scientifically proven to be hazardous to human health. It contributes to coronary heart disease, sudden infant death syndrome, and childhood asthma. It is the leading preventable cause of death worldwide.
Second Clue: Some countries are increasing production based on the mistaken belief that selling more of this product will rescue them from debt. However, estimates by the Centers for Disease Control in the United States indicate that consumer use leads to extraordinary healthcare costs and loss in labor productivity—up to $193 billion in from 2000 to 2004. Raising prices through taxation is a sure bet to reduce adolescent consumption while gaining revenue, but poor countries are only beginning to use that option.
Third Clue: Although profits reach billions of dollars, increased production doesn’t end poverty. In fact, there is evidence to the contrary. The benefits of this multibillion-dollar industry do not trickle down to farmers. Even in rich countries, such as the United States, companies are creating competitive environments result in lower income for producers. Family farms in developing countries lose as well, because production depends on the exploitation of women and children as unpaid laborers.
Fourth Clue: WHO identifies using this product as one of the four main risk factors for non-communicable diseases along with unhealthy diet, physical inactivity, and harmful use of alcohol. While fewer men are buying this good than ever, more girls and young women are using it, especially in many middle-income and developing countries. If current trends continue, the World Health Organization estimates that female deaths related to this consumer product are projected to increase from 1.5 million in 2004 to 2.5 million by 2013. Health problems for women include heart disease, infertility, low birth weight babies, and cervical cancer.
A final, give-away hint: According to a WHO report on women, gender and tobacco, more American women now die from lung cancer than from breast cancer, because they used this product.
The culprit? It is Marlboros, Milds, Benson and Hedges, Virginia Slims, Gold Leaf, and flavored tobacco for hookahs. The rise in smoking by women and girls is directly linked to the tobacco industry’s well-funded marketing campaigns targeting women. The tobacco industry uses deceptive images of beauty, modernity, prestige and liberation, while implying that light or low tar means that cigarettes are safer.
The women’s movement has been on the forefront of defending women’s rights to health and have successfully raised public issues about breast cancer, violence against women and girls, maternal mortality, and HIV/AIDS. However, more feminist health activists need to join NGOs that work to prevent non-communicable diseases (NCDs) among women, such as the Framework Convention Alliance (FCA), and NGOs that particularly focuses on tobacco use. NCDs are a major threat to women’s health, and they will soon be the leading cause of death in low-income countries. For many feminists, the facts are still hiding behind a cloud of smoke. Let’s learn the truth and clear the air.