Critical Issues in International Women’s Health

Anne Firth Murray, founder of The Global Fund for Women, past Nobel Peace Prize nominee, and consulting professor at Stanford University, gives the keynote address at the 2011 Women’s Health at Stanford Forum.

Thank you so much for inviting me. I consider it an honor to be invited to speak today at this at this forum. I truly appreciate it and when I thought about what I wanted to talk about and what I was been asked to talk about, which is International Women’s, Health or more specifically, critical issues in international women’s, health and I looked At the program, I was trying to link what I have to say as directly as possible to the program, and I didn’t succeed very well as I looked through the topics all of which I think are very interesting, and I am going to Stay around this afternoon to attend, as many as I can.

I didn’t, see direct links with what I would like to speak about today or will be speaking about today. But, as I thought about it, especially last night, I thought no. I think I can draw this together, at least to link the international to the domestic, if not to the specific topics that you’ll, be discussing in panels this afternoon.

So why talk about women? Women are at the center. All know that we’re here. Are there any men out there? Maybe there are, I hope, so. I hope we have some diversity in this group. Women are at the center of their families and their communities and, as Len mentioned, they present differently in different workplaces.

So we need to look at at women in particular because of the strategic importance in families and communities, but also because women are different, have different needs and and and illnesses and injuries affect them differently for men.

It seems to me, but today let me say that my focus is on poor women or resource poor women in resource-poor countries. That’s. What I’ve, been looking at ever since I began the Global Fund for women and have been teaching at Stanford, so the odd the the people that I’m looking at in my research and my writing are different.

I think from the focus we have today at the in the other panels. I began working with women internationally and was invited to speak at at Stanford in 2001 and when I was invited to teach, I think they thought I would come and teach once or so.

But I’ve been teaching for the whole 10 years, two courses at least a year since 2001. The head of the human biology program said to me, while I’m, really delighted that you’re going to be teaching at Stanford.

I said what do you have in mind? I mean he said anything you like as long as it has to do with women and international issues, and so I said well what I’d, like to do perhaps his teach a class on international women’s, health, and he said That would be wonderful because many of our students in human biology are pre-med and they’re headed for careers in medicine and health, and so I began to put together a class on international women’s.

Health very quickly, because at that time I became very interested in human rights issues. I decided that I was going to be looking at a class on International Women’s, Health and Human Rights, a human rights lens, and so I began to think about this class.

To put it together, what would I teach? How would I teach it? What kinds of issues would be would be covered in this class? There were so many issues that one could look at, and so I thought about it and looked at some of the International Health textbooks.

When I looked under women in the indexes of these International Women’s, Health, not Women’s; Health, but international public health textbooks. I looked under women in the index and I would come to a chapter one chapter in the book on maternal and child health.

Always women’s. Health internationally was conceived as maternal and child health. I thought went beyond that and thought. Surely they are going to cover something having to do with violence? I looked under violence in the indexes of the international public health books, textbooks that were being used at that time and I came to a chapter on traffic accidents and I thought, oh, my gosh.

Surely there must be, I mean I know I’d spent ten years at the Global Fund for women, responding to women’s groups around the world writing to us about their issues, not necessarily health issues, but human rights issues, and I Knew there were many many issues that I wanted to cover in a course.

So what I did was go back to the Global Fund for women files that I had the board books and I began to look at the proposals and the grants that we had been making at the Global Fund for women over the pre is ten years.

When I had been there, the Global Fund continues. It’s more than 20 years old now, and I began to look at these proposals and analyze them and clump them together under various categories, to see what issues women themselves had been writing about and that they had thought were so important that they Actually would perhaps form a group and try to find some money to deal with some of these issues and as I did this, I came across many specific issues, some of which I want to mention today.

But I also saw that the issues tended to find themselves under four broad categories that I would call critical critical issues in international women’s. Health and those four broad categories are first being born a woman, the demeaning of women, the discrimination against women.

The disempowering of women, one broad category that women’s groups were working on that issue in general, the second, not in any order of importance. The second broad category of critical issues that I would that I would describe is poverty.

The second is poverty. Women are the poorest of the poor in all countries. The third overarching issue of that. I would also include as a women’s. Health and human rights issue is unequal access to certain services services such as health care, education, food and nutrition and money.

The cash economy, unequal access to healthcare, unequal access to a variety of care, health care, education, food and cash, the cash economy and the fourth area that, where these these proposals seem to cluster, were under the topic of violence, not just domestic violence, but other kinds of Violence, rape, the sort of common kinds of violence, but violence like female genital mutilation or the violence, injuries and illnesses that that women face in conflict and circumstances.

So I began to sort of conceive of my class around these four broad areas of critical issues and when I say critical issues, I mean the issues that mean life or death for women depending on whether or not they can exercise their human rights so critical issues.

Those issues that mean life or death depending on whether or not they can exercise their human rights and, as I began to think about these issues and look further into the proposals that women sent. I began to provide developed categories of issues that I thought I would teach about in my class at Stanford and I began to think.

How can I do this? Shall I just randomly kind of suggest issues that we can talk about the first week that each quarter is ten weeks long? How would I organize it? What would be the organizational principle – and I decided in my class that I would use as a kind of organizing principle, a woman’s, life from infancy through old age or let’s, say women’s lives from infancy Through old age – and so I organized my class that way – and I also organized the book this way – the book that was mentioned earlier from outrage to courage – I need to get some water excuse me and so beginning with a general overview of human rights.

In my class and in the book, I start with infancy, the very beginning of a life infancy, and we look at issues of son preference, sex, selective abortion and female infanticide in parts of the world, notably parts of China, not all of China, but in parts of China parts of India, parts of Bangladesh, and formally though this is changing in parts of Korea, the the life expectancy for infant males and compared with infant females is totally out of whack in many of these places, so you’ll, find that normally, in A normal circumstance, infant boys there will be a hundred and six infant boys surviving to age five compared with about a hundred infant girls, but in some places of China, particularly in China and India, you’ll, find the ratio coming up to a hundred And twenty-six boys to a hundred girls, 152 boys to a hundred girls where the demography of the population is completely unbalanced and there are all kinds of ramifications to that which we can talk about if there’s time, but that we begin then, with This tremendously intense son preference, which results in sex selective abortion now that modern technology is available for sex selection in many countries, many places in the world, sex, selective abortion and in some places where people can’t afford modern technology to select for sex.

Then infanticide is used, so we look at that early on in my class, when we’re looking at infancy, we then move to childhood and look at the sort of overarching, terribly important issue of Education: education, unequal access to education.

Now education is one of the good news stories around International Women’s, Health more and more girls and boys are going to school. The gaps between girls, attendance to school and boys still persists, mostly because girls drop out of school at greater numbers than boys in elementary school.

But more girls are going to school and more boys are going to school in most parts of the world and we’re talking. You know about Africa, Asia, Latin America, various poor raised resource, poor countries in those regions, so education is a tremendously important determinant of women’s, health as part of general socio-economic level, which is correlated quite directly to a health status, and so it we Look at education as a health issue as a human rights issue and as a health issue in childhood, when we’re looking at children, we also look at child labor, child abuse and the what is sometimes described as a traditional practice, mostly in Africa.

It’s, not really a traditional practice, but it’s, a practice that that has been labeled, that female genital mutilation. You know I’m. I don’t know how many people are familiar with this practice, which one might describe as as violence.

It’s, it’s, the cutting of the genitalia for various reasons, the female genitalia going far beyond what circle? What would be compared with male circumcision? Some two million girls, in mostly in sub-saharan Africa, are at risk of being gently cut now, even now this is still persists, and in some countries more than ninety percent of girls are are genitally cut.

It’s. Obviously, a health risk it’s done in circumstances that are often not not safe and girls die. Girls are injured through this process, so at in childhood we look primarily at education and female genital mutilation.

Let me remind you that all of the issues that I’m, mentioning are the issues that women themselves had been writing to the Global Fund about women from all the various countries that we mentioned had written to us about wanting to do something about These issues so everything I’m mentioning and the topics in my class and my book were derived from my experience at the Global Fund for women, interacting with women’s groups around the world.

So we move on to adolescents in adolescence. The issues that we look at the girls and women’s. Health issues are primarily early child early marriage and early child birth, as most people would know, early marriage, early child, birth, girls, marrying or not marrying, but giving birth under the age of 18, or particularly even younger, 13 and 14, is not a not a healthy thing.

To do their bodies are not ready for it. Often these girls are malnourished and it’s incredibly difficult for them from the point of view of health and, one might say, Human Rights in terms of their lives.

So we look at early early marriage and early childbirth, an important issue because about half of all girls age 18 around under the age of 18 around the world are married or have given or have become mothers.

So we have 50 % of girls worldwide under the age of 18, giving birth and being married, sometimes not being married but giving birth. I also look under that week when we look at adolescents. I also look at HIV and AIDS.

I locate that in adolescence, because adolescent girls between the ages of 12 and 19 in all countries are the fastest-growing group of people contracting HIV 12 to 19. The therefore they’re, very vulnerable, HIV and AIDS, the problem of HIV and particularly relating to women, could be located at any time of a person’s life there’s.

A danger at you know in mother to child transmission. Whatever, as we look at HIV, we could look at it at different ages, including even aging, where, because of the proliferation of AIDS orphans, older women, particularly again in sub-saharan Africa, have become the caregivers of or of children orphaned by AIDS.

But I located in adolescents. In my class and in my book, because I think it’s totally outrageous that had girls between the ages of 12 and 19 are the fastest growing group contracting HIV. Why? First of all we women are very vulnerable to HIV.

We’re three to seven times at least more likely to contract HIV in a single sexual encounter than our men. We have a lot of fleshy tissue and we are more vulnerable to the virus, but adolescent girls are even more vulnerable because they are not as easily able to negotiate safe sex and they simply are again biologically vulnerable to the virus.

So we move on into womanhood. Other issues it’s, a sad tale that I’m, telling the the issue of International issues of women’s; health, critical issues in international women’s; health; it’s; a sad tale, even As you look at the more recent statistics on, many of these issues is still a sad tale.

Things are getting a little better with regard to education, and things are getting a little better. With regard to the issue that I am about to talk about under the topic of womanhood, and that is moving from looking at early marriage and early child birth in adolescence, we look at reproductive health issues in womanhood reproductive health issues again having to do with issues Like maternal mortality, there’s a little bit of good news around maternal mortality for the past 20 years.

Since I’ve been now it’s more than 25 years since I’ve been working in this field of international women’s, health and I began at the Hewlett Foundation running the population program. They’re working on reproductive health issues, primarily and population issues, reproductive health issues.

Ever since I began, we’ve, been using the same general statistic that is, that about 500,000 women a year die only looking at maternal mortality, not maternal morbidity as well. Maternal mortality. Around 500,000 women a year died of almost completely preventable pregnancy and childbirth.

Related illnesses and injuries. Now that’s, the the good news is that that statistic has declined. I mean the numbers have declined down and that’s good, because the numbers of people have increased, so the percentages are much better, but now we think with some new studies that have been done, that about 350,000 to 400,000 only 350,000 to 400,000.

Women are dying each year from almost completely preventable pregnancy and childbirth, related illnesses and injuries, and I, when I was thinking about the title for the book, I called it from outrage to courage.

This is another outrage. This is an unbelievable outrage because we know how to avoid pregnancy and childbirth related deaths, not totally, but we to these deaths these 350,000 to 400,000 only about a thousand women a day.

These deaths are happening among poor women in poor countries. That’s, that’s where it’s happening where people are not able to have assistance at the time of childbirth, and so on. So in that, we also look in that week on reproductive health at the availability and the tremendous importance of providing safe and legal abortion, contraception and safe and legal abortion, so that people can avoid multiple births when they don ‘

T want another child. Having choice around this and the the immense importance of the availability of safe and legal abortion, there are other things to talk about in this. Under this whole issue of reproductive health, but the greatest outrage to me is the maternal mortality rates.

After the talking about about reproductive health in my class and in my book, I move on to the issue that could have dominated the entire work of the Global Fund for women, and that is violence. Violence against women, particularly domestic violence.

In the 1990s I retired from the Global Fund in 1996 in the early the time of the 1990s from 1985, when the internet of the third International Conference on women was held in Nairobi to 1995, when the fourth International Conference on a United Nations conference on women Was held in Beijing in that period of time there was tremendous tremendous increase in interest among women to form groups to form networks, to begin to deal with some of these human rights issues and health issues and human rights issues, and that central issue that we saw At the Global Fund in the early nineteen 1990s was proposal after proposal after proposal having to do with violence against women, the development of rape, crisis centers, the development of Refuge, refuge centers for women.

I remember the Global Fund for women gave the first grant to many of these groups, one in Korea, one in Belize and many other countries where women came together to ask for help in setting up some sort of program to deal with what became I don &.

# 39 t think it became an epidemic, but it probably always was, but we began to be more open about it. Women were more willing to speak about domestic violence. It’s, still a very private issue. It’s, an issue that’s, always been behind closed doors doors, but more and more as women came together in these international conferences and other and in other avenues they began being willing to talk about the tremendous prevalence of violence.

There were a number of studies done over these years on the prevalence of violence in various countries in this country. A good number of groups had had studied violence and come up with the statistic that one out of three women in this country, based on a number of studies in this country, one out of three women would experience violence in we’re.

Talking now about domestic violence, not rape and other kinds of vibe other kinds of violence, but domestic violence, one out of three women would experience violence at the hands of an intimate partner in her lifetime, and that was the figure that was given.

But nobody believed it because there was never a really good study. But around 2004, the World Health Organization teamed up with the London School of Tropical Medicine and did a very extensive study of 26 countries, very thorough, credible study and they came out with the pretty much the same statistic.

One out of three women. Some countries have higher levels of violence than others. South Africa is a an example of a very violent country, but on average in general country across 26 countries, at least one out of three women will experience violence at the hands of an intimate partner or a family.

We would include honor killings and a number of other practices that are sometimes called traditional practices within that definition of violence, domestic violence, death or injury at the hands family members, and I locate violence at the center of my of my class.

I think it’s. Absolute Remender, slea m — portent and I’ll, come back to that later, as I try to link the international issues to the local issues, because here is an issue that is as local as it is international domestic violence, no question at all about It it is an epidemic and an outrage.

I believe I move on into the intensification of violence into the next section of my class in my book, and that is women in war and Conte and refugee circumstances. I never would have included that in my class.

If I had been sitting around thinking, what issues would I cover in a class on International Women’s, Health and Human Rights? What issues would I cover and usually, if there’s time, I ask people what issues would you have covered, but I didn’t think there would be time, so I wouldn’t have covered this.

This issue of women in conflict and refugee circumstances, but remember I went back to all the proposals from the Global Fund for women and I went through these hundreds and hundreds and hundreds of proposals and and grants, and I realized that group after group had been writing To us about what they were trying to do around women in conflict and Refugee circumstances, women in Kosovo, Rwanda, Congo, here there in yan around the world – and I found I I guess I used the word outrage quite often – but the level of violence that women experienced In these circumstances is really unbelievable: now men experience violence to die and are injured.

It’s true, but now, with Wars being more and more civil wars, wars within countries, we see them all around the world. They’re about 30 conflicts that have been defined as wars in right now in in the world.

We see more and more civilian casualties and, to a tremendous extent, women and children, obviously in Iraq and Afghanistan, as well as we read almost every day in the paper. So women suffer greatly in this in this area of war, and I mean I guess it’s so obvious it’s silly to say, but the numbers are pretty staggering: a number of women and children moving from place to place refugees.

Women being dislocated from their homes and suffering violence, domestic violence in particular, I might mention, though it’s different, but it’s very interesting to me that in natural disasters, similar things happen where you have societies breaking down and sort of Being the usual relationships breaking down the systems and structures in societies breaking down, and I hadn’t really given much thought to natural disasters, especially since I what I was putting together my class in terms of what the women had written to us at The Global Fund for women, but a couple of students in my class in the last couple of years, have written their blogs or their.

We do blogs in my class but papers on women’s, health and natural disasters, and I learned that in the tsunami in South Asia, Southeast Asia, for example, twice as many women died as men in the tsunami in Southeast Asia.

What I mean, why is this? Well, it was partly because they couldn’t swim because they ran down to the seashore to try to rescue their children to stayed there to try to get their children to leave and and take them with them.

They died at twice the rate of men in the Southeast Asian tsunami and apparently that statistic holds for other natural disasters. I haven’t, read the material on it, but I, but we do know that if that statistic, doesn’t hold, that is more women dying than man.

The levels of violence rise hugely in areas of natural disaster, and that is now being documented in Haiti. After the earthquake there it’s, probably being documented elsewhere. I don’t know. Maybe it isn’t being, but I was shocked by that statistic.

So as we sort of emerged from these terribly serious discussions of war – and I wish I had the time to talk about what I do in my class about the feelings that people have as they’ve, come through week after week about these really Difficult terribly difficult, women’s; health issues that we move on to a discussion of women at work in the era of globalization and it’s, a huge topic, but suffice it to say.

Under that week we talked about export processing zones. Young women being hired, it does give them a job but being hired in many countries around the world as very cheap and very compliant labor, and there are health consequences to this very widespread use of young women in factories around the world, producing pretty much everything we Have on today in our shoes and our clothes within that question of globalization and work really what I’m, looking at in my class, is women’s, access to money, their desire for work, and we also discuss in at that.

In that week, another major health issue, and that is trafficking in women as women attempt to find ways to earn money, particularly young women. They are easily trafficked, so they are hired to go somewhere to move to a different country.

Their passports are taken away whatever. There are health issues around women forced into prostitution. There’s, much to say about it, but I’ve, had a note that I have to hurry along here. Finally, we come to the topic that is dear to my heart, and that is ageing, where we look at women internationally and the question of Aging, and that is a very difficult issue to talk about internationally, because there’s, so little written about it.

Aging I mean there there’s, much written about aging of women and men in this country in the Western democracies. You know Europe and so on, but if you’re looking at resource poor countries and poor women within those countries, very little has been written about Aging in these countries.

But we do know that ageing women in poor countries, poor women, are for the most part illiterate. Often isolated in rural air is do not have access to good health care are the poorest of the poor. Often they still are the carriers of culture, and they often are the caregivers and again in South, particularly in southern Africa.

Older women are, are the caregivers, so I must come around and finish off here. I’m, told to say that many of these issues are so foreign to us female genital mutilation. Well, incidentally, it happens here, but among refugees and immigrants.

But a number of these topics – don’t seem to apply. Maternal mortality. Fortunately, has disappeared to a great extent, not in this country, but there are some issues that are cross-cultural, that cross Nations.

One of those is access to safe and legal abortion, which is so important to women’s, health, the other central one. I would say: is violence domestic violence operating really happening at about the same rate in this country, as in other countries, and having the same sort of results in terms of ill health and public health costs in countries huge costs relating to domestic violence.

Another one is access to money: equal pay for equal work, which doesn’t exist in this country, yet women are still paid less than men for equal work. The problem is much more dire in other countries in terms of access to cash and and money and the cash economy.

Actually, what else I don’t want to forget one, because I did want to relate these issues to to the domestic scene: poverty, poverty. There are obviously pockets of poverty in this country where and that poverty translates into ill health for women and men.

But since women are the poorest of the poor, it translates into ill health for women, primarily, so it’s. A sad story. I apologize for that. I don’t want it to be a negative. I don’t want to end hundreds and hundreds of groups.

Both women’s. Groups and other groups are working on these issues. My interest now, as I move forward in my own research and teaching, is to identify the most promising interventions for these many many issues that I’ve talked about to try to find those local efforts.

Often they are local national. Whatever efforts to deal with these issues, we have an awful lot of activity internationally, an immense amount of money spent, particularly in the reproductive health area, but in some of these other areas, much of it not terribly effective.

If you look and wonder why that is we see that often suggestions or interventions are interventions? They are interventions that come from the outside, rather than pure support for strengthening and empowering people on the ground which, in my experience, turns out to be the most effective kind of help.

So again it’s, a sad story, the International story. It relates to some degree to our national or our domestic issues, not terribly much to the topics that are covered today, but there is hope out there and there are a lot of people working actively on it.

I’m going to be around for the afternoon, and so if anyone would like to pursue any of these thoughts, I’ll be hanging around and I would look forward to hearing questions or comments. Unfortunately, there wasn’t enough time for Question and Answer, but thank you very much.

The preceding program is copyrighted by the Board of Trustees of the Leland Stanford junior University. Please visit us at med.stanford.edu.

Leave a comment

Your email address will not be published. Required fields are marked *