Human rights and women's health: global goals in small places

The title of Anne Firth Murray's book, From Outrage to Courage: Women Taking Action for Health and Justice, neatly encapsulates both the history she documents and, I expect, the stories she hopes to inspire: of women (and men, although they do not feature prominently) who are driven to act by their profound sense of injustice and their commitment to changing their communities. Murray's portrayal of the evolution of the women's health movement over the past 20–30 years focuses on the enormous gender inequities and biases that persist, and which fundamentally affect the health of women and girls in much of the developing world today. We are 7 years away from the target date for achieving the Millennium Development Goals (MDGs), which include MDG 3, to achieve gender equality and empower women, and MDG 5, to improve maternal health. Although Murray's book devotes little attention to the global arena of UN agencies, major donors, and international non-governmental organisations where the MDGs are much discussed and measured, her prologue hones in on a debate that is embodied in these two MDGs: whether the promotion of women's health should be approached by focusing on women's ill-health as a violation of human rights and justice, or as an impediment to economic development. Murray comes down firmly in support of the human rights perspective. In an ideal world, her argument would win; policy makers, donors, local chiefs, and husbands around the world would see the unfairness of women's lot and pass laws, provide funds, and change attitudes and practices so that women's health would be protected and gender equality would be achieved. But the reality is that if change is going to happen fairly quickly, and on the scale necessary to transform women's place in society, decision makers (primarily male ones) need to be convinced; and experience shows that focusing on the economic bottom line, and not on fairness, is the most effective way to convince these people. Yet this does not need to be an “either-or” debate, as Murray herself acknowledges in her discussion of investments in girls' education: both the justice and economic arguments “are reasonable” in this context. The critical factor is to ensure that the investments, policies, and programmes that are mobilised by economic arguments are then framed through a human rights lens, thereby reflecting the priorities and needs of the individuals they are intended to help. After this initial debate, From Outrage to Courage settles down to provide a convincing, hard-hitting, and at times relentlessly discouraging portrait of how girls and women are undervalued, neglected, and victimised. Murray traces the consequences of gender bias throughout the life cycle: from sex-selective abortion, female infanticide and neglect of girl infants and children; through female genital mutilation and early marriage and childbearing; the greater risk of HIV infection borne by adolescent girls and women; on through the health risks and complications of pregnancy and childbearing; and ending with an absorbing analysis of discrimination against older women. Along the way, she stops to examine the prevalence of violence against women, arguing that “domestic terror” may be a more appropriate term than “domestic abuse” for a phenomenon that so profoundly dominates the minds, as well as the bodies, of the women who suffer through it. Her exploration of women in conflict situations includes a fascinating (if horrifying) analysis of rape as an instrument of war. When membership in a community is seen as based on ethnicity, then women are the “reproducers” of that community identity. Mass rape, therefore, is not only an instrument of terror, but is also a way to destroy that community physically, by forcibly impregnating women with the offspring of another ethnic group. The consequences of such practices are tragically articulated by the Rwandan woman who lost seven children in the genocide, and is left only with a child born of the violence, who she cannot love. Although the analysis, the arguments, and most of the information in From Outrage to Courage are on target, there are some surprising omissions and out-of-date facts. In the chapter on women's reproductive health, for example, medical abortion is given only a passing mention, despite its potential to increase access to a relatively safe and effective method of pregnancy termination. In the chapter on the plight of refugees, there is no mention at all of emergency contraception, which should be an essential element of any package of health services for refugee populations. The figures presented on maternal mortality are from 1995, even though revised estimates for 2000 had been out for several years before the publication of this book late last year. The discussion on the legal status of abortion does not list several countries, including South Africa, Nepal, and Guyana, which have liberalised legal grounds for abortion in the past several years (as well as countries such as Nicaragua that have gone in the opposite direction). And the examination of family planning does not hit hard enough at the stagnation, and in some cases decline, in the availability of effective contraceptives in many countries, and the lack of progress in addressing the unmet need for family planning globally. From Outrage to Courage should not perhaps be used as a primary reference for anyone looking for the facts and figures on the topics it addresses. What it does do, very effectively, is to convey broad issues that are at the heart of Murray's argument: that women's health and women's status in society are interlinked, and that progress in one realm cannot and will not be made without progress in the other. The question that Murray leaves us with is how these interlinked challenges will be addressed. Her implicit answer, sprinkled in dozens of examples throughout the book, is that the collective impact of community-level women's groups will ultimately generate the momentum to change societies. These brief descriptions of women coming together to fight a problem and forge solutions are indeed inspiring, and show both the courage and the outrage of the title. It will be a long, slow fight, however, if we must wait for such small-scale action to effect the transformation that is needed. We must hope that the existence of global goals for women's empowerment and health will inspire change at the policy level as well; with both movements aiming for the same outcomes success may be in sight.