Handbook on Gender and Health 1784710865, 9781784710866

This Handbook brings together a groundbreaking collection of chapters that uses a gender lens to explore health, health

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Handbook on Gender and Health
 1784710865,  9781784710866

Table of contents :
Front Matter......Page 1
Copyright......Page 4
Contents......Page 5
Figures......Page 8
Tables......Page 9
Boxes......Page 10
Contributors......Page 11
Acknowledgements......Page 21
PART I INTRODUCTION......Page 23
1. Gender and health: an introduction......Page 25
PART II GENDER, HEALTH AND PUBLIC POLICY......Page 45
2. Agenda-setting in women’s health: critical analysis of a quarter-century of paradigm shifts in international and global health......Page 47
3. Gender, health and climate change......Page 67
4. Towards a new political agenda for indigenous women’s health in Latin America in the post-2015 era......Page 82
5. Dangerous discourses? Silencing women within ‘global mental health’ practice......Page 101
6. Cost-cutting, co-production and cash transfers: neoliberal policy, health and gender......Page 120
7. Applying a genders lens to public health discourses on men’s health......Page 139
8. Men, ‘masculinity’ and mental health: critical reflections......Page 156
9. Stigmatized, marginalized and overlooked: health, later life and gender in India and the United Kingdom......Page 170
PART III GENDER, WORK AND HEALTH......Page 185
10. Gender, work and health: a step forward in women’s occupational health......Page 187
11. Intersectionality: the value for occupational health research......Page 211
12. Gendered work violence issues and mental health among Chilean women workers......Page 225
PART IV GENDER, MIGRATION AND HEALTH......Page 243
13. Migration, gender and health......Page 245
14. Migration and health in a Chinese context: examining the linkages through a gender lens......Page 257
15. Engendered movements: migration, gender and health in a globalized world......Page 273
16. Migration and sex work in South Africa: key concerns for gender and health......Page 290
PART V GENDER AND HEALTH SYSTEMS......Page 303
17. Gender equity and the politics of health sector reform: overcoming policy legacies and forming epistemic communities......Page 305
18. Gender and commercialization of health care......Page 320
19. Commercialization in maternity care: uncovering trends in the contemporary health care economy......Page 331
20. Building post-conflict health systems: a gender analysis from Northern Uganda......Page 349
21. Reproductive health care and indigenous peoples in Venezuela......Page 373
PART VI HOUSEHOLDS, HEALTH AND HEALTH CARE......Page 395
22. Cycles of violence in gendered social contexts: why does child maltreatment lead to increased risk of intimate partner violence in adulthood?......Page 397
23. Capacities to exercise strategic decision-making agency: exploring the gendered production of health within intimate partnerships and households......Page 416
PART VII GENDER, SOCIAL ACTIVISM AND HEALTH......Page 439
24. Citizen monitoring: promoting health rights among socially excluded women in Andean Peru......Page 441
25. Emergent masculinities, men’s health and the Movember movement......Page 458
PART VIII GENDER, HEALTH, SEXUALITY AND RIGHTS......Page 477
26. Men’s sexual health and destiny......Page 479
27. Claiming Rosa Parks: conservative Catholic bids for ‘rights’ in contemporary Latin America......Page 496
28. Conservative backlashes to women’s bodily integrity in Latin America: the case of Chile......Page 510
29. Deconstructing human rights-based discourses: the case of women’s right to health and health sector reforms in Brazil......Page 527
30. Men, masculinities and health in Brazil: a feminist critique......Page 544
31. Sexual health or rights? USAID-funded HIV/AIDS interventions for key populations in Ghana......Page 561
32. Positive women managing reproduction in the HIV pandemic......Page 583
Index......Page 597

Citation preview

HANDBOOK ON GENDER AND HEALTH

Jasmine Gideon - 9781784710859 Downloaded from Elgar Online at 11/03/2017 02:47:53AM via Sydney University

INTERNATIONAL HANDBOOKS ON GENDER Series Editor: Sylvia Chant, FRSA, Professor of Development Geography, London School of Economics and Political Science, UK International Handbooks on Gender is an exciting new Handbook series under the general editorship and direction of Sylvia Chant. The series will produce high quality, original reference works offering comprehensive overviews of the latest research within key areas of contemporary gender studies. International and comparative in scope, the Handbooks are edited by leading scholars in their respective fields, and comprise specially commissioned contributions from a select cast of authors, bringing together established experts with up-and-coming scholars and researchers. Each volume offers a wide-ranging examination of current issues to produce prestigious and high quality works of lasting significance.   Individual volumes will serve as invaluable sources of reference for students and faculty in gender studies and associated fields, as well as for other actors such as NGOs and policy-makers keen to engage with academic discussion on gender. Whether used as an information resource on key topics, a companion text or as a platform for further study, Elgar International Handbooks on Gender aim to provide a source of definitive scholarly reference.   Titles in the series include: The International Handbook on Gender, Migration and Transnationalism Global and Development Perspectives Edited by Laura Oso and Natalia Ribas-Mateos Handbook on Gender and Health Edited by Jasmine Gideon

Jasmine Gideon - 9781784710859 Downloaded from Elgar Online at 11/03/2017 02:47:53AM via Sydney University

Handbook on Gender and Health

Edited by

Jasmine Gideon Senior Lecturer, Development Studies, Birkbeck, University of London, UK

INTERNATIONAL HANDBOOKS ON GENDER

Cheltenham, UK • Northampton, MA, USA

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© Jasmine Gideon 2016 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical or photocopying, recording, or otherwise without the prior permission of the publisher. Published by Edward Elgar Publishing Limited The Lypiatts 15 Lansdown Road Cheltenham Glos GL50 2JA UK Edward Elgar Publishing, Inc. William Pratt House 9 Dewey Court Northampton Massachusetts 01060 USA

A catalogue record for this book is available from the British Library Library of Congress Control Number: 2015957879 This book is available electronically in the Social and Political Science subject collection DOI 10.4337/9781784710866

ISBN 978 1 78471 085 9 (cased) ISBN 978 1 78471 086 6 (eBook) Typeset by Servis Filmsetting Ltd, Stockport, Cheshire

01

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Contents List of figuresviii List of tablesix List of boxesx List of contributorsxi Acknowledgementsxxi PART I  INTRODUCTION   1 Gender and health: an introduction Jasmine Gideon

3

PART II  GENDER, HEALTH AND PUBLIC POLICY   2 Agenda-­setting in women’s health: critical analysis of a quarter-­century of paradigm shifts in international and global health Ramya Kumar, Anne-­Emanuelle Birn and Peggy McDonough   3 Gender, health and climate change Sarah Payne

25 45

  4 Towards a new political agenda for indigenous women’s health in Latin America in the post-­2015 era Anna Coates and Sandra Del Pino

60

  5 Dangerous discourses? Silencing women within ‘global mental health’ practice79 Rochelle Ann Burgess   6 Cost-­cutting, co-­production and cash transfers: neoliberal policy, health and gender98 Deborah Johnston   7 Applying a genders lens to public health discourses on men’s health James A. Smith, Noel Richardson and Steve Robertson

117

  8 Men, ‘masculinity’ and mental health: critical reflections Brendan Gough, Steve Robertson and Mark Robinson

134

  9 Stigmatized, marginalized and overlooked: health, later life and gender in India and the United Kingdom Penny Vera-­Sanso

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vi  Handbook on gender and health PART III  GENDER, WORK AND HEALTH 10 Gender, work and health: a step forward in women’s occupational health Lucía Artazcoz, Imma Cortès-­Franch and Vicenta Escribà-­Agüir

165

11 Intersectionality: the value for occupational health research Rima R. Habib, Kareem Elzein and Nadia Younes

189

12 Gendered work violence issues and mental health among Chilean women workers203 Elisa Ansoleaga Moreno, Ximena Díaz Berr and Amalia Mauro Cardarelli PART IV  GENDER, MIGRATION AND HEALTH 13 Migration, gender and health Lorena Núñez Carrasco 14 Migration and health in a Chinese context: examining the linkages through a gender lens Jasmine Gideon

223

235

15 Engendered movements: migration, gender and health in a globalized world Denise L. Spitzer

251

16 Migration and sex work in South Africa: key concerns for gender and health Marlise Richter and Jo Vearey

268

PART V  GENDER AND HEALTH SYSTEMS 17 Gender equity and the politics of health sector reform: overcoming policy legacies and forming epistemic communities Christina Ewig 18 Gender and commercialization of health care Meri Koivusalo and Sarah Sexton 19 Commercialization in maternity care: uncovering trends in the contemporary health care economy Susan F. Murray

283 298

309

20 Building post-­conflict health systems: a gender analysis from Northern Uganda327 Sarah N. Ssali, Sally Theobald, Justine Namakula and Sophie Witter 21 Reproductive health care and indigenous peoples in Venezuela Johanna Gonçalves Martín

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Contents  ­vii PART VI  HOUSEHOLDS, HEALTH AND HEALTH CARE 22 Cycles of violence in gendered social contexts: why does child maltreatment lead to increased risk of intimate partner violence in adulthood? Karen Devries, Heidi Grundlingh and Louise Knight 23 Capacities to exercise strategic decision-­making agency: exploring the gendered production of health within intimate partnerships and households Rachel Tolhurst, Esther Richards, Eleanor MacPherson, Dorcas M. Kamuya, Flavia Zalwango and Sally Theobald

375

394

PART VII  GENDER, SOCIAL ACTIVISM AND HEALTH 24 Citizen monitoring: promoting health rights among socially excluded women in Andean Peru Jeannie Samuel 25 Emergent masculinities, men’s health and the Movember movement Sara Smith and Marcia C. Inhorn

419 436

PART VIII  GENDER, HEALTH, SEXUALITY AND RIGHTS 26 Men’s sexual health and destiny Matthew Gutmann

457

27 Claiming Rosa Parks: conservative Catholic bids for ‘rights’ in contemporary Latin America Lynn M. Morgan

474

28 Conservative backlashes to women’s bodily integrity in Latin America: the case of Chile Gabriela Alvarez Minte

488

29 Deconstructing human rights-­based discourses: the case of women’s right to health and health sector reforms in Brazil Marianna Leite

505

30 Men, masculinities and health in Brazil: a feminist critique Jorge Lyra and Benedito Medrado 31 Sexual health or rights? USAID-­funded HIV/AIDS interventions for key populations in Ghana Benjamin Eveslage 32 Positive women managing reproduction in the HIV pandemic Lesley Doyal

522

539 561

Index575

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Figures 10.1 Time devoted to domestic work among European workers, married or cohabiting170 10.2 Person who contributes the most to the household income among European workers, married or cohabiting 171 15.1 Conceptual framework 252 20.1 Map of Uganda showing the Acholi sub-­region 328 20.2 Wealth index distribution by gender 336 20.3 Male household head, 50 years 337 20.4 Female household head, 51 years 338 20.5 Female household head, 63 years 339 22.1 Exposure to maltreatment 377 22.2 Factors influencing trajectories after child maltreatment 378 22.3 Effects of maltreatment in early and later adulthood 379 23.1 Conceptual framework 395 28.1 Ratio of female to male of the population (ages 15 to 64) that actively engages in the labour market by adolescent fertility rates in Latin America and countries belonging to the OECD 490

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Tables   5.1 Details about articles included in mapping of discourse 85   5.2 Community mental health competencies 93 10.1 Labour force participation in Europe by country and sex, 2013 (per cent) 167 10.2 Part-­time employment as a percentage of total employment by sex and country, 2013 168 12.1 Violence by occupational group and sex 208 12.2 Exposure to psychosocial risks in the workplace, by gender (percent) 211 12.3 Associations between psychological harassment and workplace psychosocial risks by gender 212 12.4 Salaried victims of violence, by whether they consume psychotropic drugs, with or without distress, and with symptoms of depression by gender213 12.5 Bivariate analysis of exposure to workplace violence and psychological distress, symptoms of depression and consumption of psychotropic drugs among men and women 214 20.1 Mini survey sample selection 330 20.2 Showing the initiatives being undertaken to enable community members to access health care 332 20.3 Economic empowerment by gender 335 20.4 Household health events after war 336 20.5 Strategies to pay for health care 341 31.1 List of interviewees 541

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Boxes   5.1 Case history, patient P field notes, 15 November 2010 91 23.1 Gendered intra-­household bargaining and decision-­making around treatment for febrile children 402 23.2 Male crew members’ livelihoods and decision-­making around sexual relationships404 23.3 Older women and men’s accounts of agency, health and well-­being over their life cycles 406 23.4 Decision-­making around research participation: what matters 408

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Contributors Gabriela Alvarez Minte has a PhD from Birkbeck, University of London, UK and holds an MSc in Sociology from the University of Oxford, UK. Prior to pursuing the PhD she worked as a Programme Specialist for the Latin American and Caribbean Section at the United Nations Entity for Gender Equality and the Empowerment of Women (UN Women) in New York, USA, and previously in the same position at the United Nations Development Fund for Women (UNIFEM). She holds a Social Anthropology degree from the Universidad de Chile, and worked for several years in a non-­governmental organization in Chile. Elisa Ansoleaga Moreno is an Associate Professor at Diego Portales University, Chile in the Faculty of Psychology, and a Researcher in the Psychosocial Studies at Work Programme. She is also on the academic staff for the Masters in Social Psychology and the Doctorate in Psychology at Diego Portales University. She is the Principal Researcher in the project ‘Organizational Dimensions of Violence at Work in Chile: A Study in Three Economic Sectors Addressing Occupational and Gender Differences’, Universidad Diego Portales – Center of Women’s Studies (CEM). Lucía Artazcoz has been the Director of Health Promotion at the Public Health Agency of Barcelona, Spain since 2004, and Associate Professor at the Pompeu Fabra University, Spain and John Hopkins University, USA. She completed her PhD in Public Health at Pompeu Fabra University. Her research interests lie in the area of work-­related social inequalities in health and gender inequalities in health. Anne-­Emanuelle Birn is Professor of Critical Development Studies (University of Toronto Scarborough, UTSC) and Social and Behavioural Health Sciences (Dalla Lana School of Public Health) at the University of Toronto, Canada and served as Canada Research Chair in International Health (2003–2013). Professor Birn’s research explores the history and the politics and political economy of international and global health, with interests in Latin American health and social justice movements, child health and rights, philanthrocapitalism, and the societal determination of health; and emphases ranging from the scatological to the ideological. Her books include Marriage of Convenience: Rockefeller International Health and Revolutionary Mexico, Oxford University Press’s Textbook of International Health: Global Health in a Dynamic World, and Comrades in Health: US Health Internationalists, Abroad and at Home. Rochelle Ann Burgess is a Lecturer in Health and Social Care at London Metropolitan University, UK and Research Associate, Health Economics and HIV/AIDS Research Division (HEARD) University of KwaZulu-­Natal, South Africa. Rochelle is a community health psychologist with expertise in global health promotion. Her work highlights the value of community-­based approaches to health in global settings, and takes interest in the interface between global health concerns and broader development issues such as poverty, governance, power relations and community mobilization (civil society). xi Jasmine Gideon - 9781784710859 Downloaded from Elgar Online at 11/03/2017 02:47:53AM via Sydney University

xii  Handbook on gender and health Anna Coates is currently Chief of Gender and Cultural Diversity at the Pan American Health Organization, following her prior post as United Nations Entity for Gender Equality and the Empowerment of Women (UN Women) Deputy Regional Director for the Americas and the Caribbean, and other UN positions. She previously worked in academic research and teaching related to gender, ethnicity, development and health (particularly maternal health programme evaluation) and was Oxfam GB Global Gender Advisor. Her PhD in Gender from the London School of Economics (LSE), UK focused on indigenous women’s access to health care in Chiapas, Mexico. Imma Cortès-­Franch is a public health doctor. She works at the Occupational Health Department in the Public Health Agency of Barcelona, Spain. Her research focuses on the analysis of gender and social class inequalities in health, especially those related to working and employment conditions of paid work, and also the characteristics of domestic and family unpaid work. Sandra Del Pino is currently the Cultural Diversity Advisor at the Pan American Health Organization. Her previous experience includes work on gender and human rights at the Western Pacific Regional Office of the World Health Organization in Manila, the Philippines, as well as extensive human rights work at the United Nations Office of the High Commissioner for Human Rights in Geneva, Switzerland. Karen Devries is a Senior Lecturer at the London School of Hygiene and Tropical Medicine, UK. Dr Devries is a social epidemiologist with more than 13 years of experience conducting research on violence against women and children and adolescent health. Her work includes a programme of primary research in East Africa focusing on the development of violence prevention interventions in primary and secondary schools, large-­scale cluster randomized controlled trials to test their effectiveness, cross-­sectional surveys, qualitative and economic research, and methodological work. She has published more than 40 peer-­reviewed journal articles, including in Science, the Lancet and PLOS Medicine. Ximena Díaz Berr is a Sociologist from the University of Chile and is a Researcher at the Center of Women’s Studies (CEM) in Santiago, Chile and a specialist in gender studies, work and health. She is the Coordinator of the projects ‘Research, Policy and Practice with Regard to Work Related Mental Health Problems in Chile: A Gender Perspective’, ‘Validation and Standardization of Inventory of Violence and Psychological Harassment at Work IVAPT-­PANDO. An Instrument for the Prevention of Workplace Violence as a Risk Factor for Mental Health’, ‘Development and Validation of an Instrument Enabling to Measure External Violence, Risk Factors and their Effect on the Mental Health of Chilean Workers’, and co-­ researcher of the project ‘Organizational Dimensions of Violence at Work in Chile: A Study in Three Economic Sectors Addressing Occupational and Gender Differences’, all projects of the Universidad Diego Portales–CEM. She is a Member of the Consultative Council of the Gender Equality Observatory in the Chilean Ministry of Health. Lesley Doyal was educated in Sociology and Social Policy at the London School of Economics, UK and is now Emeritus Professor of Health and Social Care at the University of Bristol, UK. Her books include The Political Economy of Health (1979)

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Contributors  ­xiii and What Makes Women Sick (1995). Her research activities over the past decade have focused mainly on issues relating to the global HIV pandemic, with human rights as a key theme. This is reflected in her latest book Living with HIV and Dying with AIDS: Inequality, Diversity and Human Rights in the Global Pandemic (Ashgate, 2013). Kareem Elzein holds an MPH in Health Promotion and Community Health from the American University of Beirut, Lebanon. He is currently pursuing a PhD in Comparative Education at the University of California, Los Angeles, USA. He has worked on topics including refugee and labour rights, and social movements. Vicenta Escribà-­Agüir is a public health doctor in the Health Promotion and Biomedical Research Foundation (FISABIO), Valencia, Spain. She is also an Associate Lecturer at the University of Valencia, Spain. She completed her PhD in Public Health at Alicante University, Spain. Her main areas of research lie on work-­related social inequalities in health and gender (violence and psychosocial risk factors). Benjamin Eveslage is a consultant to FHI 360 on the LINKAGES project. He holds an MSc in Research for International Development from the School of Oriental and African Studies, University of London, UK. His research focuses on analysing the experience of marginalized populations within processes of transcultural change and international development practice. For a total of 15 months working in Ghana (between 2008 to 2015), he has taken on a number of capacities including fieldwork with sexual minorities, key populations and sexual health organizations. From these experiences and research endeavours he hopes to highlight the tensions and prospects for joint health and human rights approaches in international development. Christina Ewig is a Professor in the Departments of Gender and Women’s Studies and Political Science at the University of Wisconsin-­Madison, USA. She has published widely on gender and health sector reforms in Latin America. Her book, Second-­Wave Neoliberalism: Gender, Race and Health Sector Reform in Peru (Penn State University Press, 2010) won the Flora Tristán award for best book on Peru from the Peru Section of the Latin American Studies Association. Her articles on gender and social policy reforms have appeared in Social Science and Medicine, World Development and Social Politics, among other journals. Jasmine Gideon is a Senior Lecturer in Development Studies at Birkbeck, University of London, UK. She is the author of Gender, Globalization and Health in a Latin American Context (Palgrave Macmillan, 2014) and the co-­ editor of Migration, Health and Inequality (Zed Press, 2013). Her current research explores health and well-­being among the Latin American community in the UK. Johanna Gonçalves Martín is an anthropologist with a medical background. She worked for several years with the Yanomami in Venezuela, first as a medical doctor and epidemiologist, and more recently as an anthropologist. For her doctoral dissertation at the University of Cambridge, UK she conducted ethnographical research on the intersection between health professionals’ reproductive and sexual health care practices, and Yanomami people’s practices around fertility and well-­being. Her main interests are the anthropology of health, illness and healing practices; gender; translation and intercultural communication; global health; and comparative Amazonian anthropology.

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xiv  Handbook on gender and health Brendan Gough is a critical social psychologist and qualitative researcher interested in men and masculinities. Now based at Leeds Beckett University, UK, he has published many papers on gender identities and relations, mostly in the context of health, lifestyles and well-­being. Professor Gough is a co-­founder and co-­editor of the journal Qualitative Research in Psychology; he edits the Critical Psychology section of the journal Social and Personality Psychology Compass, and is Associate Editor for the journal Psychology of Men and Masculinity. Heidi Grundlingh is a Research Fellow at the London School of Hygiene and Tropical Medicine, UK. As a social epidemiologist, she collaborates with a non-­governmental organization partner (Raising Voices) in East Aftrica to articulate the theory of change for a child violence primary prevention programme in schools and further programme development and adaptation from primary to secondary schools (Good Schools Toolkit). Her primary research experience includes methods such as randomized control trials to test intervention effectiveness, cross-­sectional surveys and qualitative research. She also has experience in developing, monitoring and evaluating child health and psychosocial programmes in Southern Africa. Matthew Gutmann is Professor of Anthropology and Director of the Brown International Advanced Research Institutes at Brown University, USA. His research has focused on men and masculinities, politics, public health and militaries, and his books include The Meanings of Macho: Being a Man in Mexico City, The Romance of Democracy: Compliant Defiance in Mexico City, Fixing Men: Sex, Birth Control and AIDS in Mexico and Breaking Ranks: Iraq Veterans Speak out against the War (with Catherine Lutz). Most of his ethnographic research has been conducted in Mexico; he has also conducted collaborative research on and with United Nations peacekeepers in Haiti and Lebanon; and more recently launched a comparative project in Mexico City and Shanghai. Rima R. Habib is Professor of Environmental and Occupational Health at the American University of Beirut, Lebanon. She has been the Chair of the Technical Committee on Gender and Work in the International Ergonomics Association since 2009. Her research – doubly focused on marginalized workers and unrecognized labour – aims to highlight the intersections of work, gender, environment and health. Marcia C. Inhorn is the William K. Lanman Jr Professor of Anthropology and International Affairs at Yale University, USA. A medical anthropologist focusing on gender and health issues, Inhorn has conducted numerous research projects on the social impact of infertility and the emergence of assisted reproductive technologies to overcome both male and female infertility. She is the author of five books on the subject, including her most recent, Cosmopolitan Conceptions: IVF Sojourns in Global Dubai (Duke University Press, 2015), which focuses on global reproductive travel. Inhorn is also the founding editor of the Journal of Middle East Women’s Studies (JMEWS), and co-­editor (with Soraya Tremayne) of Berghahn’s ‘Fertility, Reproduction, and Sexuality’ book series. Deborah Johnston is a Reader in Development Economics at the School of Oriental and African Studies (SOAS), University of London, UK. She has worked on sub-­Saharan Africa for more than 20 years, researching rural labour markets, poverty, welfare and

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Contributors  ­xv health. Of relevance for this Handbook is her work on HIV and nutrition in sub-­Saharan Africa. Dorcas M. Kamuya is a Researcher in Ethics and Community Engagement on the Global Bioethics Network, at the Ethox Centre, University of Oxford, UK. Her research centres on developing and evaluating community engagement strategies in Kilifi, Kenya, and facilitating sharing of experiences between programmes in Kenya, Thailand, Malawi, Vietnam and South Africa. Louise Knight has a background working on  HIV prevention trials and HIV/ARV clinic cohorts in East Africa and South Africa. Her more recent work has been situated within  humanitarian medical non-­ governmental organizations strengthening health information systems and operational research. She is employed by the London School of Hygeine and Tropical Medicine (LSHTM), UK, in the Gender Violence and Health Centre as the Trial Manager for the ‘Good Schools Study’, a cluster randomized ­controlled trial of a school-­based intervention designed to reduce violence in schools. Meri Koivusalo is a Senior Researcher in the National Institute for Health and Welfare, Helsinki, Finland. She has written broadly on international health policy, health and trade and commercialization and health. Ramya Kumar is a Doctoral candidate in Social and Behavioural Health Sciences at the Dalla Lana School of Public Health, University of Toronto, Canada. Having completed her undergraduate degree in Medicine at the University of Peradeniya in Sri Lanka, she practiced as a Medical Officer with the Ministry of Health before commencing her graduate studies. Her research interests span a range topics, including social and health inequalities, Third World women’s health, and the politics of international and global health. She holds a Master of Science in Global Health and Population from the Harvard School of Public Health, USA. Marianna Leite is an independent researcher and practices international human rights law  in Rio de Janeiro, Brazil. She completed her PhD in Development Studies at Birkbeck, University of London, UK where she used a Foucauldian discourse analysis to explore the significant shifts in maternal mortality reduction policies over the past decades in Brazil. This research was the extension of the work she conducted as a visiting scholar at the International Gender Studies Centre at the University of Oxford, UK. Jorge Lyra has a PhD in Public Health from the Oswaldo Cruz Foundation (FIOCRUZ), Brazil. He is a Professor at the Federal University of Pernambuco, Brazil, where he teaches postgraduate psychology courses. He develops projects that combine teaching, research and social intervention on issues related to health, communication, gender, feminism, men and masculinities, integrating interdisciplinary fields of knowledge as social psychology and public health. He is Coordinator of the Center for Research on Gender and Masculinity, and one of the founders of the non-­governmental organization the PAPAI Institute, both in Recife, Brazil. Eleanor MacPherson is a Postdoctoral Researcher at the Liverpool School of Tropical Medicine, UK. Her work to date has focused on how the broader social environment

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xvi  Handbook on gender and health shapes men and women’s vulnerability to ill-­health. Her doctoral research investigated HIV transmission and transactional sex in fishing communities in Southern Malawi. Amalia Mauro Cardarelli has a degree in Sociology from the University of Paris VIII, France and a Masters in Urban and Regional Development, College of Mexico. She is the Director of the Center of Women’s Studies (CEM), Santiago, Chile. She is a Co-­researcher on the project ‘Research, Policy and Practice with Regard to Work-­ Related Mental Health Problems in Chile: A Gender Perspective’, Universidad de Ottawa – CEM; and Co-­researcher on the projects ‘Validation and Standardization of Inventory of Violence and Psychological Harassment at Work IVAPT-­ PANDO. An Instrument for the Prevention of Workplace Violence as a Risk Factor for Mental Health’, ‘Development and Validation of an Instrument Enabling to Measure External Violence, Risk Factors and their Effect on the Mental Health of Chilean Workers’, and ‘Organizational Dimensions of Violence at Work in Chile: A Study in Three Economic Sectors Addressing Occupational and Gender Differences’, all projects of the Universidad Diego Portales – CEM. Peggy McDonough is Professor in the Dalla Lana School of Public Health at the University of Toronto, Canada. Her research centres on comparative life course dynamics and the social aspects of health, including inequalities, gender relations and employment. Her work appears in a range of sociology and social epidemiology outlets, such as the American Journal of Sociology, Journal of Health and Social Behavior, Work, Employment and Society, Gender, Work and Organization, Social Science and Medicine, Advances in Life Course Research and the Journal of Epidemiology and Community Health. Benedito Medrado has a PhD in Social Psychology from PUC-­São Paulo, Brazil. He is a Professor at the Federal University of Pernambuco, Brazil, where he teaches postgraduate psychology courses. His work combines teaching, research and social intervention on issues related to health, communication, gender, feminism, men and masculinities, integrating interdisciplinary fields of knowledge as social psychology. He is the Coordinator of the Centre for Research on Gender and Masculinity and one of the founders of the non-­governmental organization the PAPAI Institute, both in Recife, Brazil. Lynn M. Morgan is Mary E. Woolley Professor of Anthropology at Mount Holyoke College in Massachusetts, USA. She is a medical anthropologist and author of Icons of Life: A Cultural History of Human Embryos (University of California Press, 2009), as well as numerous articles about reproductive ideologies and foetal politics. She is currently writing about the backlash against reproductive rights movements in Latin America. Susan F. Murray is Professor of Health, Society and Development at King’s College London, UK. A Sociologist in the International Development Institute, her research examines how health systems can generate or prevent health and wider social goals. She has addressed questions related to poverty and access to health care, the commercialization of health care, globalization and the health care economy, the social organization of health care, and maternal and reproductive health policy. Justine Namakula is a Research Fellow at Makerere University School of Public Health, Uganda. She holds an MPhil in gender and development studies and is currently working towards a PhD at Queen Margaret University Edinburgh, UK. She coordinates

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Contributors  ­xvii all ReBUILD sub-­projects and also leads the project on ‘Health Worker Incentives in Uganda’. Her work has focused on health workers’ life histories, effects of conflict on their lives and professions as well as the evolution of health worker incentive policies during and after the conflict in Northern Uganda. Lorena Núñez Carrasco is a Medical Anthropologist and obtained her PhD from Leiden University in 2008. She is a Lecturer in Health Sociology at the Department of Sociology, University of the Witwatersrand, South Africa. Lorena has researched on various issues related to gender and migration as well as the linkages between migration, livelihoods and HIV/AIDS and, more recently, on experiences of faith healing with African Independent and Pentecostal churches. Her recent co-­edited book entitled Healing and Change in the City of Gold brings together alternative ways of coping and support among new urban communities in post-­apartheid Johannesburg. She is co-­editor of the book Routes and Rites to the City: Mobility, Diversity, and Religious Space in Johannesburg (forthcoming) that explores urban diversity through the lens of religious practices. She also has an interest in the topics of death, funeral, burials and end-­of-­life care among cross-­border migrants. Sarah Payne is Professor in Health Policy and Gender at the School for Policy Studies, University of Bristol, UK. Her research interests include gender equality and gender equity in health and health policy, poverty, exclusion and health, and global health governance. Esther Richards is a Postdoctoral Researcher and Lecturer in Research Methods at the Liverpool School of Tropical Medicine, UK. Her research centres on gender equity in health and development, with a particular focus on reproductive health and rights, religion and post-­conflict contexts, including Timor-­Leste, Northern Uganda, Sierra Leone and Mozambique. Noel Richardson is Director of the National Centre for Men’s Health at the Institute of Technology Carlow, Ireland. He has extensive experience in the area of men’s health at a research, policy and advocacy level. He is principal author of the first ever National Policy on men’s health, which was published in Ireland in 2009 and is also co-­author of the State of Men’s Health in Europe Report published in 2011. He is a board member of the Men’s Health Forum in Ireland and the European Men’s Health Forum. Marlise Richter has worked as a Researcher at Project Literacy, the AIDS Law Project, the Treatment Action Campaign and the Reproductive Health and HIV Research Unit, in South Africa.  She holds  a PhD in Public Health  and her research focused on sex worker access to health care services in sub-­Saharan Africa. She works within the Policy Development and Advocacy unit at Sonke Gender Justice and holds visiting researcher positions at the School of Public Health and Family Medicine, University of Cape Town, South Africa and at the African Centre for Migration and Society, Wits University, South Africa. Steve Robertson is Professor of Men, Gender and Health at Leeds Beckett University, UK. His main research interests are around social theories of masculinity and their application to aspects of health and health promotion. He has extensive experience of evaluating a range of men’s health promotion interventions. Most recently he has completed

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xviii  Handbook on gender and health several commissions for the Movember Foundation considering the evidence about what works for men in terms of promoting mental well-­being, and the role of ‘masculinity’ in men’s mental well-­being. Steve has more than 50 peer-­reviewed publications in the field and wrote what became a seminal text, Understanding Men and Health, in 2007. He has worked with fellow academics, policy-­makers and practitioners from Australia, the United States and Canada and has acted as a consultant on gender and men’s health to the UK Department of Health and to the World Health Organization (Europe). Mark Robinson is a Research Fellow at the Centre for Men’s Health, Institute for Health and Wellbeing, Leeds Beckett University, UK. With more than 20 years’ research experience since 1995, he has particular interest in researching men and mental health, ageing and gendered identities, men’s well-­being at work, arts and mental health, and black and minority ethnic men’s health. Jeannie Samuel is currently an Assistant Professor at the University of Western Ontario’s School of Health Studies, Canada, where she teaches in the area of health promotion. Jeannie also has extensive professional experience on gender and health-­related issues, working with United Nations agencies in Latin America and Africa as well as with community groups in inner-­city Toronto, Canada. She is based in Toronto. Sarah Sexton is a Researcher and Editor who has worked for many years with the Corner House, UK and other social justice movements. James A. Smith is an Associate Professor and works in the Office of Pro Vice Chancellor – Indigenous Leadership at Charles Darwin University, Australia. He has a longstanding research interest in men’s health, and the nexus between gender, equity and health policy development. He has worked in numerous executive and management roles in health and education strategic policy and planning settings in both governmental and non-­governmental contexts in the Northern Territory, Australia. He is a Fellow of the Australian Health Promotion Association and is an Associate Editor of the International Journal of Men’s Health and the Health Promotion Journal of Australia. Sara Smith is an advanced PhD student at the Yale University Department of Anthropology, USA. Her dissertation research examines the relationship between oncology, global health sciences and the lived experience of people with cancer in the Arab Middle East. Denise L. Spitzer is a Professor in the Institute of Feminist and Gender Studies at the University of Ottawa, Canada where she served as the Canada Research Chair in Gender, Migration and Health and a Principal Scientist in the Institute of Population Health for a decade. In addition to undergraduate studies in Biology, Chinese Language, and Music, she holds a Master’s degree and Doctorate in Anthropology from the University of Alberta, Canada. She is interested in examining how global processes – intersecting with gender, racialization, migration status and other social identifiers – are implicated in health and well-­being. Professor Spitzer has published in journals such as Gender and Society, Medical Anthropology Quarterly and the Canadian Journal of Public Health. Her edited collection, Engendering Migrant Health: Canadian Perspectives, was published by the University of Toronto Press in 2011, and was recognized in 2013 with a Women’s and Gender Studies et Recherches Féministes (WGSRF) Outstanding Scholarship citation.

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Contributors  ­xix Sarah N. Ssali is a Senior Lecturer at the Makerere University School of Gender Studies, Uganda and holds a PhD in International Health Studies. She is a co-­principal investigator on the ReBUILD Uganda Project in Uganda, where she leads the research project on analysing patterns in household health expenditure in Gulu District, Northern Uganda. Her work focused on how the war changed households’ ability to meet their members’ health care needs, and how this affected especially the poorest households’ capacity to navigate the new health care market engendered by the war. She is active on the Research in Gender and Ethics: Building Stronger Health Systems (RinGs) steering committee. Sally Theobald is a Professor of Social Science and International Health at the Liverpool School of Tropical Medicine, UK and member of the Gender and Health group. Her work focuses on gender equity and health systems strengthening in Africa and Asia. She is active on the Research in Gender and Ethics: Building Stronger Health Systems (RinGs) steering committee. Rachel Tolhurst is a Senior Lecturer in Social Science and International Health at the Liverpool School of Tropical Medicine, UK. Her research centers on gender and equity in health systems, in Asia and Africa, including work on maternal health, post-­abortion care, intimate partner violence, child marriage, and gender equity in scientific careers. Jo Vearey holds a PhD in Public Health and is an Associate Professor with the African Centre for Migration and Society, University of the Witwatersrand, South Africa and holds a Senior Fellowship with the Center for Peace, Democracy and Development, McCormack Graduate School of Policy and Global Studies, University of Massachusetts, Boston, USA. Jo’s research focuses on migration and health in southern Africa and she has published widely. Jo is involved in a range of international partnerships including with the VU University, Amsterdam, the Netherlands; University of Massaschusetts, Boston, USA; University of Oldenburg, Germany; and the London School of Hygiene and Tropical Medicine, UK. Penny Vera-­Sanso is Senior Lecturer in Development Studies and Social Anthropology at Birkbeck, University of London, UK. She has published widely on ageing, gender and poverty in urban and rural India, directed multidisciplinary, international research projects on ageing and poverty in India, and made two documentaries on older people in India, The Forgotten Generation and We’re Still Working. She is currently developing research on older people’s social and economic roles in the London Borough of Hackney, UK. Sophie Witter is Professor of International Health Financing and Health Systems at Queen Margaret University Edinburgh, UK. She leads a research project on health worker incentives within the ReBUILD consortium, which studies health system reconstruction post-­conflict. Her work has focused on reducing financial barriers to accessing health care in low-­and middle-­income countries, particularly for mothers and newborns, and on provider payment mechanisms which incentivize good-­quality care for all. Nadia Younes holds an MA in Middle Eastern Studies from the American University of Beirut, Lebanon. She is an advocate for refugees’ rights. Her years of experience as an organizer in marginalized communities have provided her with insights in understanding the issues that affect underserved populations.

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xx  Handbook on gender and health Flavia Zalwango is a Social Scientist working with the Medical Research Council, Uganda’s Research Unit on AIDS. Since 2008 she has undertaken research involving women at high risk of HIV and sexually transmitted infections (STIs) and older people, focusing particularly on the impact of HIV on their lives. She is currently researching parenting interventions for preventing gender-­based violence.

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Acknowledgements I would like to thank Sylvia Chant who first invited me to compile this book and has continued to offer support and encouragement as it has been written. I am also extremely grateful for the excellent cover design and the use of Suelle Nachif’s wonderful image. Thanks also to Alex O’Connell at Edward Elgar Publishing who helped me through the different stages of its production. Special thanks are due to Marianna Leite for all of her invaluable assistance, particularly in contacting authors, ensuring we all met our deadlines and generally keeping it all together. I am also grateful to Gabriela Alvarez, Susan Murray and Penny Vera-­Sanso for helpful comments and feedback on the volume and the introductory chapter. Finally, I would like to extend my thanks to all the contributors who responded so positively to the initial invitation and have maintained their ­enthusiasm for the volume throughout.

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PART I INTRODUCTION

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1.  Gender and health: an introduction Jasmine Gideon

This volume brings together the contributions of 56 leading writers on gender and health from a wide range of countries spanning Africa, the Americas, Asia, Europe and the Middle East. The chapters included in the Handbook offer a wealth of knowledge, theoretical reflection and empirical evidence on a diversity of topics that I selected as essential elements of a discussion around gender and health. The importance of gender inequality as a critical determinant of health has been widely acknowledged (Marmot et al., 2008) and there has been a widespread acceptance of the need to mainstream gender into its analysis. Nevertheless, significant gaps remain between policy and practice, and addressing gender issues in health requires more than merely ensuring women gain better access to services and resources within the health sector (Gideon, 2012; Hawkes and Buse, 2013; Payne, 2014). The discussion within the book emphasizes the need to move beyond the ‘add women and stir’ approach that is still frequently found in practice, despite all we now know about the complexities of seeking to achieve gender equality (Chant and Sweetman, 2012; Razavi, 2012). Much of the existing debate around gender and health has been primarily concerned with health outcomes; in contrast the discussion presented in this edited collection seeks to capture the multi-­determinants of health and well-­being as well as the organizational and institutional structure of the design and delivery of health care. In the context of economic and social change, the collection considers how these factors are altered and how far processes of change are gendered, as well as how far gender relations impact on these shifting dynamics. A significant and distinctive feature of this Handbook is that many of the chapters explore these challenges through empirical case studies from a variety of geographical settings in both the Global North and the Global South and illustrate that ‘gender’ remains central to any analysis of health, regardless of the level of development within the health system or wider economy. Moreover, the chapters offer a wealth of disciplinary perspectives, presenting critical insights and a diversity of approaches to the study of gender and health. Four overarching themes are broadly explored in the book and all constitute what might be considered as distinct but overlapping elements of a broader gendered political economy of health (Gideon, 2014). The first theme is the tension between ideas of gender equity and gender equality and how these translate in practice when applied to the health sector. In practice gender equity approaches often boil down to a very reductionist focus on ‘women’ and fail to take into account other axes of inequality including race, caste, class, age and ethnicity, while at the same time failing to unpack the category of ‘men’ and looking more critically at the social relations between them and their female counterparts. In contrast, as discussed in more detail below, a gender equality approach can potentially enable a more transformative suite of measures likely to bring about gains in gender justice. The United Nations Entity for Gender Equality and the Empowerment of Women (UN Women) (2010) argues that gender justice entails ending the i­nequalities 3 Jasmine Gideon - 9781784710859 Downloaded from Elgar Online at 11/03/2017 02:47:53AM via Sydney University

4  Handbook on gender and health between women and men that are produced and reproduced in the family, the community, the market and the state. However, at the same time it requires that mainstream institutions are more accountable and transparent, and this points to the second theme discussed in the book. Several of the chapters reflect on the need to uncover the gendered nature of the health system itself and shed light on the diverse ways in which women’s interests are frequently marginalized or health policies work to reinforce women’s gendered roles and responsibilities. The third theme that is examined is the importance of incorporating the voices of excluded groups in policy processes, as several chapters highlight the health costs of failing to engage with marginalized sectors of society. Finally, the fourth theme that emerges from a number of the chapters is the importance of appropriate policy responses and a move away from the ‘one size fits all’ approach, often espoused by international donors and global health discourses. While success at the local level often poses the challenge of how to scale up effective policy responses, extreme caution must also be exercised when successful policy initiatives are imposed on a variety of different settings with little thought given to the local complexities that may impact on the implementation process, often with disastrous results. As all of the chapters convincingly show, gender is a central element and there is clearly a need for more nuanced and reflective debate and discussion if the gender dimensions of health and health care are to be fully understood and incorporated into practice. Overall the Handbook seeks to address the reasons why a palpable fissure between discourse and practice continues to occur. An important starting point for any gendered analysis is to critically reflect on mainstream understandings of health as merely the absence of disease. In the main the definition of health offered by the World Health Organization (WHO) has been widely used and accepted across the world. According to the WHO, ‘health’ refers to ‘a state of complete physical, mental and social well-­being and not merely the absence of disease or infirmity’ (WHO, 1948). Nevertheless, it is important to consider some of the limitations of the definition, particularly the ways in which it has been seen to reinforce particular biomedical, Western approaches to health (Hoedeman, 2011; Larson, 1999; Pannenborg, 1979). Yet these tensions between overly medicalized understandings of health, and broader approaches which take into account the ways in which the wider social context, including political and economic conditions, shape individual’s health and well-­being, remain unresolved. Moreover, the anthropologist Marcia Inhorn (2006) argues that the dominant medical focus of the definition of health is highly gendered and limits the boundaries within which people, and women in particular, can identify health problems and define their own health needs. Indeed the need for incorporating the voices of the excluded in health policy and planning is also a recurring theme in many of the chapters, and several chapters reflect on the limitations of overly medicalized approaches to health issues. As stated earlier, an important issue considered throughout the Handbook is the use of the term ‘gender’ itself. As critics have argued, even where ‘gender’ is taken on board, considerable confusion exists around the meaning and usage of the relevant terminology. Most notably the terms ‘gender equity’ and ‘gender equality’ can generate considerable misinterpretation (Payne and Doyal, 2010). This is important because the terms represent very different approaches and encompass very different political projects. In part the confusion around the terms stems from the intense debate over their usage and meaning amongst participants at the 1994 United Nations Cairo Conference on Population and

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Gender and health: an introduction  ­5 Development, to accept the promotion of both terms, along with the empowerment of women (Payne and Doyal, 2010; Petchesky, 2003). Within the health field, policy documents frequently use ‘gender’ as a shorthand for ‘women and men’ and both are seen as fixed and unproblematic categories. ‘The evidence that there is a gender problem is a statistical difference between these categories, for instance, lower rates among men of general practitioner consultation, or higher rates among women of victimization in domestic violence’ (Connell, 2012: 1675). Yet this fails to recognize important inequalities within each category of ‘women’ and ‘men’. The work of scholars such as Kimberlé W. Crenshaw (1991) has highlighted the importance of ‘intersectionality’ and of looking at the importance of other forms of difference – notably race, caste, class, ethnicity and age – which interact with gender difference. The work of Joan Anderson (2006) has focused attention on the ways in which racialized assumptions about the behaviours of particular ethnic groups raise concerns for health and well-­being. As she suggests, these assumptions can apply equally to populations of any ethnic or racial background; for example, assuming that white middle-­class people do not need support from social services on leaving hospital because they have resources of their own to pay for services, or presuming that people from ‘ethnic’ backgrounds will have an extended family available to care for them on leaving hospital, so likewise additional support is not required. Nevertheless, Anderson suggests that using the concept of racialization as process, as opposed to race as a category, can offer more analytical scope. She suggests that rather than ‘categorizing people by race, we would be examining how racial categories are constructed and how the constructions are used in everyday social encounters to categorise people in order to interpret what they do and say’ (2006: 10). Yet, as she notes, these processes of racialization ‘Are most detrimental in situations of unequal power relations, when people from some racialized categories are constructed as inferior, therefore lacking in authority and unable to fulfil some roles, or when people from some groups are constructed as needy or as expecting too much from the “system”’ (2006: 11). Even so, policy processes have tended to retain simple categorical approaches that frequently target women as a group not only distinct from, but effectively separate from, men. ‘Men and boys appear mainly as the statistical norm, or the privileged category. Categorical thinking thus underlies a very widespread problem in the health literature, where gender is named, but actually women are spoken about’ (Connell, 2012: 1676). Moreover, as Cornwall et al. assert, where women do appear in policy narratives they frequently do so as ‘both heroines and victims: heroic in their capacities for struggle, in the steadfastness with which they carry the burdens of gender disadvantage and in their exercise of autonomy; victims as those with curtailed choices, a triple work burden and on the receiving end of male oppression and violence’ (Cornwall et al., 2007: 3). Within the health sector this frequently translates as constructing women as a single universal ‘risk group’ and as the problem to be addressed. This implicitly reinforces the significance of biological difference, and women’s biological essentialism as reproducers is overly emphasized. In effect this means that their health needs are thought of solely in terms of their ability to become pregnant, give birth and nurture their children (Inhorn and Whittle, 2001; Payne, 2014). Within the health field this type of approach is often referred to as the ‘women’s health needs’ approach and is often encompassed within a

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6  Handbook on gender and health broader gender equity category. This is concerned with the implications for women of differences in the epidemiological profile between the sexes (Standing, 1997). Gender equity applies the general concept of equity in provision of health services to men and women, asking, for example, whether health systems respond equally to men and women in equal need. Such approaches attempt to address gender inequalities in health status by strengthening services to women and by drawing attention to the need for greater participation of women at all stages of health planning. Within gender equity approaches to health women are seen as a special case of beneficiaries: attention is generally given to the special needs of women as mothers, but the ways in which gender inequalities affect morbidity throughout a woman’s life are ignored. Men’s needs are not adequately addressed, for example, by ignoring their role in reproductive health and men are frequently absent as actors in gender change, or ‘remain a shadowy background’ (Connell, 2012: 1676). The importance of ‘bringing men in’ to gender work, particularly within the health sector, is discussed in several chapters of this book and has also been taken up by the WHO (Barker et al., 2007). Indeed as Smith and Inhorn (Chapter 25 in this Handbook) note, men in fact generally experience worse health outcomes than women across the world, yet few projects which systematically address the needs of men and boys alongside those of women and girls have moved beyond the pilot phase (Barker et al., 2007). Over the past couple of decades a growing body of ethnographic research has made important contributions to understandings of ‘what men say and do to be men’ (Gutmann, 1996: 17, cited in Smith and Inhorn, Chapter 25 in this Handbook: p. 437). This has led to new insights and challenges to earlier thinking around masculinities and health, and much of this work draws on Inhorn’s notion of ‘emergent masculinities’, which entail ‘change over the male life course as men age; change over generations as male youth grow to adulthood; and changes in social history that involve men in transformative social processes; [and the] new forms of masculine practice that accompany these social trends’ (Inhorn, 2012: 60, cited in Smith and Inhorn, Chapter 25 in this Handbook: p. 444). These ideas are more fully developed in several chapters of the book which draw on examples from both the Global North and the Global South to demonstrate the diverse ways in which men are actively challenging common stereotypes around health and masculinities.

ENGENDERING THE SOCIAL DETERMINANTS OF HEALTH A gendered analysis of health is not just about focusing on health outcomes, and indeed one of the most significant shortcomings of much ‘gender and health’ work is that the social relations between women and men, which are themselves bearers of gender, frequently remain unexamined and taken for granted. In 1995 Lesley Doyal’s groundbreaking work, What Makes Women Sick? Gender and the Political Economy of Health, highlighted the relationship between biomedical approaches and the gendered socio-­ economic determinants of health. She explored the gendered dimensions of women’s health, including looking at issues around work (both paid and unpaid), pregnancy, childbearing, and the impact of substances ranging from tranquillizers to alcohol. This

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Gender and health: an introduction  ­7 analysis provided an important foundation for subsequent analyses which have built on her work to illustrate the centrality of unpaid care – frequently performed by women within households – to health, and the diverse ways in which it underpins the health sector (Doyal, 2005; Gideon, 2014; Mackintosh and Tibandebage, 2006). Research has also focused on the role of gender relations in the production of vulnerability to ill-­health or disadvantage within health care systems and the conditions that promote inequality between the sexes in relation to access and utilization of services. Gender differentials in exposure and vulnerability to health risk can arise for two main reasons: the interplay of biological sex with the social construction of gender, and the direct impacts of structural gender inequalities (Sen and Östlin, 2009: 18). Indeed as Sen and Östlin (2009) observe, vulnerability is also socially rather than biologically determined and reflects an individual’s capacity to avoid, respond to, cope, and/or recover from health risks. This vulnerability can be constructed in numerous ways; for example, as a result of gender norms around women and men’s work, which may mean women are more at risk of occupational health hazards. It may also be that gender gaps in wages mean women are less able to pay for costly treatments than men. Within the health sector this type of relational approach to gender is often referred to as a ‘gender equality approach’. Such an approach is centrally concerned with power relations, and considers that health may also be a site of gender conflict. These questions are central to a number of the chapters presented in this collection and several of the authors explore a range of different dimensions of the gendered vulnerabilities to health risks, highlighting how these vulnerabilities are also shaped by class, racial and age differences. Nevertheless, one ongoing challenge faced by those working on these issues is the lack of primary data available in numerous fields related to gender and health and, even where gender-­disaggregated data is available, it is rarely aggregated by further variables such as socio-­economic position or ethnicity. Despite sustained calls for data from the international community, there still remain large gaps where evidence is not available, or is of low or anecdotal quality. This in part may reflect gendered bias in research priorities (Kuhlmann and Annandale, 2010; MacPherson et al., 2012) and is certainly an area that requires further work and investigation.

GENDER, HEALTH AND PUBLIC POLICY The chapters in Part II of the book examine some of the ways in which gender has been incorporated into public policy and considers the implications of this for health. One clear theme that emerges from the chapters is the simplistic assumptions about gender roles, responsibilities and forms of behaviour that are deeply embedded within many health policies. Yet as the chapters illustrate there is an urgent need to challenge these to ensure that policies are better able to respond to the health needs of individuals and households and to move away from a ‘one size fits all’ approach. In Chapter 2 Ramya Kumar, Anne-­Emanuelle Birn and Peggy McDonough reflect on the successive reframing of the women’s health agenda within international and global health policy. Taking a historical perspective, they consider the shifts that have occurred over the past 25 years, and point to the ways in which larger political and economic agendas have shaped international health policies, with direct consequences for women’s

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8  Handbook on gender and health health. While at certain periods the clear contribution of women’s health activism to policy framing can be seen, the authors argue that with the growing influence of the corporate sector in the global health sphere, the language of women’s rights has been co-­ opted to focus narrowly on reproductive and maternal health. Nevertheless, the authors believe that current debates about a sustainable development agenda that recognize the necessity of addressing the broad socio-­economic determinants of health, and forging links across multiple progressive constituencies, offer potential new opportunities for transnational activism to reshape the debate in more effective ways that really do place women’s health needs at the forefront of health policy processes. Moreover, as illustrated in Chapter 3 by Sarah Payne, processes of global change bring new policy challenges that point to the need for urgent responses from the health sector. Her chapter reflects on the gendered dimensions of climate change in relation to health and considers appropriate policy responses. The impact of climate change on the global system and on the way of life and health of individuals and the planet has been acknowledged in wider debates around health. Indeed the Commission on the Social Determinants of Health (2008) called for the need to address climate change alongside the need to address health inequalities. Yet as Payne highlights, while there has been a response to this call for action, much of the work has been gender blind. The impact of climate change on health and the global burden of disease is wide-­ranging and includes greater risks of premature mortality and higher morbidity, through increasing rates of a number of communicable and non-­communicable diseases and greater risks of injury. However, as Payne’s chapter clearly demonstrates these risks are also shaped by gendered norms and gendered forms of behaviour. Several chapters highlight the potential for change when there is a convergence of interest around a particular topic at a global level. This can follow what retrospectively becomes seen as a landmark international conference, such as the 1994 International Conference on Population and Development in Cairo which represents a critical moment for women’s sexual and reproductive health and rights, or the Second World Congress on Men’s Health in Vienna, Austria held in 2002. This event in Vienna marked a turning point for men’s health organizations as they subsequently became increasingly engaged in awareness building and fundraising activities to bring men’s health issues into the global health spotlight. Likewise the Millennium Development Goals focused global attention on a number of health issues, most notably HIV/AIDS and maternal and child health, with  both positive and negative consequences (Greco et al., 2008; Hsu et  al., 2013; Pitt et al., 2010). Moreover, the existence of normative frameworks at global and regional levels can offer important entry points to build political support and mandate governments to formulate and implement strategies that specifically address the needs of marginalized groups. This is explored in more depth by Anna Coates and Sandra Del Pino in Chapter 4, which argues that the post-­2015 development agenda has offered crit­ ical entry points for advancing the rights of indigenous communities in Latin America. Furthermore the existence of both global and regional normative frameworks has focused attention on the need to address the widespread gendered inequalities that exist within many of these communities, particularly in relation to health. Within Latin America indigenous populations tend to be disproportionately represented in rural, often remote, locations across the region, as well as amongst those living in situations of poverty and indigence. These factors are central in shaping their access to health care

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Gender and health: an introduction  ­9 services, ­particularly where marked urban–rural inequalities continue to exist across the region in terms of health care provision. Moreover, many indigenous communities experience racism in their encounters with health care providers, while the continued expansion of regressive out-­of-­pocket payments can further limit access to services. Global discourses can potentially produce many positive results for neglected health issues and marginalized groups, yet as Rochelle Ann Burgess warns in Chapter 5, there are also potential limitations. Her analysis examines the ways in which global discourses around health can work against the interests of the very groups they claim to support. There have been growing calls to address the mental health needs of women in the Global South, as it has been recognized that they face a series of gender-­driven risk factors including a greater likelihood to be living in conditions of poverty compared to men, exposure to violence and conflict, as well as the ‘care burden’ which has been shown to have implications for mental well-­being. The Movement for Global Mental Health was initiated in 2001 and has sought to push the issue of mental health to the centre stage through a variety of means including advocacy work and scholarly publications. A central question in Burgess’s chapter is how far the ‘voice’ of women has been incorporated into current global mental health discourses, or whether the ‘uncomfortable history of the field of psychiatry’s engagement with women’ is merely replicated in the current discourse and practice that is being extended to the Global South. She draws on the case of South Africa, where mental health care services have been developed in line with global mental health recommendations. In Chapter 6, Deborah Johnston shows how recent social policy initiatives have been informed by specific aspects of neoliberal economic thinking which fail to recognize the complexities in intra-­household decision-­making processes around health and what this might mean for health outcomes. Instead, she argues, current neoliberal thinking has reshaped the definitions of health rights, with health seen as co-­produced by the state, the private sector and the individual. Moreover, health is increasingly understood as the outcome of individual choice and people’s ‘preference’ for poor health-­seeking behaviour. This has led to a plethora of social protection initiatives, predominantly in Africa and Latin America where recipients receive cash benefits if they practice good health-­seeking behaviour. A central feature of many of these programmes is their orientation towards improving the intra-­generational transfer of poor health and thus many programmes seek to reward mothers with cash benefits if, for example, they take their children to be vaccinated. The inherent maternalism in these programmes, which reinforces women’s caring role, has been widely critiqued (Molyneux, 2006). Nevertheless, while as Johnston documents, many of these programmes have produced better health outcomes in some contexts, the evidence remains mixed and requires further investigation, particularly from a gender perspective. Although dominant neoliberal thinking suggests that individ­ uals are at fault for failing to respond to health messages, it completely fails to take into account the wider set of factors leading to poor health and how these processes may be gendered. Moreover as Johnston contends, under neoliberal reform programmes health sectors in a wide variety of countries have been restructured, reducing the role of the state in health care provision while at the same time increasing the role of the private sector and households. As she and other critics have shown, this has had significant implications for the levels of unpaid care work that is predominantly performed by women. This can then constrain women’s ability to earn higher levels of income, which in turn

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10  Handbook on gender and health can further constrain their access to health care services which have become increasingly commercialized and thus access is determined by ability to pay. At the same time, neoliberal economic reforms have had significant gendered implications for the nature of employment, with a growing number of female-­intensive forms of work in particular offering jobs that come with little or no forms of social protection attached. For those individuals and households that have been most negatively impacted by these economic and social reforms and live precarious lives, ‘choosing’ healthy behaviours is therefore sometimes not an option at all. Chapters 7 and 8 reflect on the ways in which men are frequently presented as a public health problem and consider the development of a number of policy initiatives designed to overcome this. According to James Smith, Noel Richardson and Steve Robertson in Chapter 7, the nature of ‘being a man’, one’s masculinity (whether seen as biologically driven or socially derived) means that men create a public health problem for themselves and for others. Men’s greater tendency to engage in unhealthy lifestyle practices such as drinking and smoking has led some within the public health field to identify men as ‘their own worst enemy’. At the same time, masculine norms are seen as limiting or delaying men’s take-­up of health services and therefore their health suffers further as a consequence. Moreover, male roles also drive men to engage in lifestyle practices which have the inevitable negative consequences on health outcomes. Yet when men fail to perform these gendered roles it can create ‘gender role strain’, which also has public health consequences. The authors reflect on some of the policy responses that have emerged in Ireland and Australia and offer a potential roadmap for men’s health policy development in other countries. In Chapter 8, Brendan Gough, Steve Robertson and Mark Robinson focus on the assumptions that are frequently made around men, masculinities and mental health. Their analysis highlights the need to unpack ideas around men and masculinity in order to bring new insights into men’s health-­seeking behaviour around mental health and the ways in which men’s mental health problems are understood. The chapter points to the need for an intersectional approach and emphasizes the ways in which masculinities intersect with other systems of difference and inequality related to, for example, social class, race, ethnicity, age, sexuality and disability in shaping men’s vulnerability to poor mental health as well as their coping strategies. In response to these more nuanced understandings of the role of masculinity in influencing health-­seeking behaviour, a number of ‘male-­friendly’ mental health interventions have been developed in the UK. Chapter 9 by Penny Vera-­Sanso also challenges problematic policy assumptions but her focus is on older people, particularly assumptions that position people over age 60 as vulnerable, dependent and a burden on society. Comparing the discourses on dementia in the UK and failing family support in India, she shows how problematic these assumptions are and how they mask the reality that many older people continue to play an active role in the economy through both paid and unpaid work, which is essential for not only their own health and well-­being (for example through their sense of being a contributor, rather than a ‘burden’, and through their ability to pay for services) but also contributes to the well-­being of their families and of society. Vera-­Sanso argues that widespread negative stereotypes and prejudicial discourses about older people’s needs, wants and capacities drive the overlooking of their social and economic contributions and the marginalization of their rights, and leave these factors out of the equation in investigating

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Gender and health: an introduction  ­11 older people’s health and well-­being. Failing to address the structural obstacles to participation can only deepen inequalities between older people, and these inequalities reflect a lifetime of inequalities based on gender and class.

GENDER, WORK AND HEALTH The chapters in Part III reflect on the linkages between gender, work and health and highlight how the role of gender is frequently overlooked in discussions around occupational health. Yet all three chapters clearly demonstrate that work is a highly gendered – and racialized – social determinant of health. The authors reflect on the gendered nature of the labour market and consider how gendered norms can not only constrain women’s access to the labour market as a consequence of their unpaid caring responsibilities, but also shape the types of job opportunities that are available to women, and indeed men. Moreover, the nature of work is critical in shaping gendered vulnerabilities to poor health as a consequence of occupational health risks, while also determining women and men’s differential access to services; for example through the availability of employment-­related social protection benefits such as sick pay, or through wage levels which determine the ability to pay for services or make out-­of-­pocket payments. While gender norms have historically located men in work such as heavy manual labour, thus exposing them to greater occupational health risks, today many women are located in the informal economy where they lack social protection, generally earn lower wages than men and are frequently exposed to new occupational health risks. Nevertheless as Lucía Artazcoz, Imma Cortès-­ Franch and Vicenta Escribà-­Agüir argue in Chapter 10, little is known about the role of gender in occupational health risks as women’s health risks are frequently excluded or overlooked in research. Yet gender differences in work have important implications for occupational health risks: while for example musculoskeletal problems among men are very much related to heavy loads, among women they are more likely to be associated with the type of repetitive work women often perform, for example in sewing garments or fruit picking. Gender is also cross-­cut by social class and race in shaping exposure to occupational health risks, and the role of masculinities must also be considered. In Chapter 11, Rima Habib, Kareem Elzein and Nadia Younes reflect on the question of incorporating intersectionality into occupational health research. One ongoing challenge, they assert, is that many occupational health researchers are unfamiliar with and lack training in useful qualitative methodologies that might provide instrumental insights, and tend to be more versed in quantitative approaches. Yet as the authors maintain, some of the assumptions around conducting intersectional quantitative research include access to large databases, as well as access to funds or resources that do not exist in poorer countries. Researchers from the Global South can also become marginalized in processes around the production of knowledge, and an approach that takes intersectionality into account can also offer new entry points for health researchers in less privileged positions. Chapter 12 focuses on the growing concern of psychosocial hazards and mental health issues in the workplace. Elisa Ansoleaga Moreno, Ximena Díaz Berr and Amalia Mauro Cardarelli reflect on the ways in which workplace violence and psychological harassment, widely acknowledged as major working life stressors, are becoming increasingly

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12  Handbook on gender and health recognized as a serious public health issue. Despite evidence that shows a high prevalence of mental health and workplace violence issues among women workers, research into the links between mental health, work and gender are relatively under-­researched. Their chapter draws on empirical findings from Chile and shows how the gendered nature of labour markets has meant that women are more likely to occupy low-­paid, low-­status forms of work. Despite widespread evidence to the contrary, women’s paid work is often viewed as of secondary importance to the household and men continue to be considered the primary breadwinners. At the same time the gender division of labour within the household continues to place prime responsibility for unpaid care work onto women. These processes continue to limit women’s participation in the labour market and often mean that few opportunities are available to them, sometimes giving them little choice regarding the type of work they do and locating them in precarious forms of employment where they are often more exposed to psychosocial hazards than their male counterparts. As a consequence women are at a greater risk of workplace violence and experience a higher prevalence of mental health issues than men. Nevertheless, the chapter also shows how men are also affected, and particularly those men located in more precarious forms of work.

GENDER, MIGRATION AND HEALTH Acknowledging the voices of the excluded is particularly pertinent when exploring the relationship between gender, health and migration, another widely recognized social determinant of health. In Part IV, chapters by Lorena Núñez Carrasco (Chapter 13), Jasmine Gideon (Chapter 14) and Denise Spitzer (Chapter 15) examine these linkages and show how central gender roles and norms are in relation to shaping the health and well-­being of migrants. The chapters draw on a range of disciplinary perspectives and all three locate their analysis across different empirical settings in both the Global North and the Global South, but the evidence in all three cases demonstrates the importance of the gender division of labour to migration, in terms of both household decision-­making about who migrates, but also the centrality of women’s unpaid care work in shaping employment opportunities available to many migrant women and how such processes are also cross cut by racial, class and income inequalities. Núñez Carrasco’s chapter conceptualizes migration as a gendered and embodied experience, and hence the centrality to look at health which represents the cumulative effects of the social forces on migrants’ bodies. Her analysis illustrates the importance of considering the gender-­related health risks associated with different stages of migration. These include health-­related decision-­ making at the pre-­migration stage, the risks and vulnerabilities migrants may face during the migratory process, adaptation into the host society and finally, return migration. She presents the concepts of vulnerability and structural violence and discusses their suitability to understand the different positions men and women migrants occupy through the various phases of migration and the differential impact of migration on their health status. In Chapter 14, Gideon focuses on the case of internal migration within China and shows the importance of considering the linkages between home and migrant communities which are often ignored in health policy, yet are also highly gendered. In Chapter 15, Spitzer reflects on the ways in which the health impacts of migration are often invisible

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Gender and health: an introduction  ­13 under a biomedical lens, yet for many migrants the precarious nature of their lives has a significant effect on their well-­being but their health issues remain unresolved. All three chapters reflect on the gendered nature of these processes and illustrate the implications for health policies and outcomes. In Chapter 16, Marlise Richter and Jo Vearey explore the complex intersection of gender and health through the cases of male, female and transgendered migrant sex workers. The analysis draws on experiences within South Africa, a country associated with high levels of population mobility – both within the country and across borders – and where sex work is illegal and sex workers are frequently denied the right to health. The chapter reviews a range of structural and gendered vulnerabilities experienced by migrant sex workers that are associated with increasingly restrictive immigration legislation, the criminalization of sex work, a strong anti-­trafficking agenda, conservative international donor restrictions and negative public opinion. In particular it highlights the absence of voice of migrant sex workers themselves in terms of defining their health needs and appropriate services, and reflects on the ways in which restrictive donor policies around sex work have further limited the possibility of developing partnerships with sex worker organizations. Nevertheless, the discussion within the chapter draws together evidence which stresses the potential for health care services to play a transformative role in the material conditions of sex workers and to develop clear directives which can offer sensitive and effective responses to the health needs of sex workers.

GENDER AND HEALTH SYSTEMS The need to recognize health systems as social institutions has been widely acknowledged, and as Gilson (2003: 1453) suggests, ‘Health systems are inherently relational and so many of the most critical challenges for health systems are relationship problems’. Yet a growing body of work has emerged that reveals how these relationships are also shaped by historically embedded gendered and racialized norms which in turn produce outcomes that reflect these biased norms (Ewig, 2010; Gideon, 2014; Goetz, 1997). In Chapter 17, in Part V, Christina Ewig draws on the case of Peru in the 1990s and explores how these historically embedded norms – or policy legacies – become reproduced over time through health reform processes. She focuses on the power relations between interest groups as well as institutions within health systems and identifies the mechanisms which, during periods of policy reform, privilege certain interest groups and institutions over others. Ewig’s chapter shows how the complexity of health systems with multiple layers of providers and extensive workforces creates a wide range of potential interest groups each seeking to uphold an entrenched set of policies, while also upholding an entrenched set of privileges that frequently reinforce gender, race and class distinctions. Her chapter also looks at how reform processes can create specific entry points for the influence of epistemic communities or ‘expert’ groups, and how competing communities fight for influence over the nature of the reform process. However, as Ewig further demonstrates, in the Peruvian case, despite the presence of a gender-­conscious rights-­based epistemic community this lacked a strong anchor within the bureaucracy or ties to key decision-­ makers and so was limited in its efforts to influence policy outcomes.

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14  Handbook on gender and health The pervading influence of neoliberal epistemic communities on health systems is further explored in chapters by Meri Koivusalo and Sarah Sexton (Chapter 18) as well as Susan Murray (Chapter 19). Lynn Freedman et al. have asserted that ‘Health systems can be a vehicle for fulfilling rights, for active citizenship, and for true ­democratic ­development – poverty reduction in its fullest sense’ (Freedman et al., 2005: 997). Nevertheless, as Koivusalo and Sexton as well as Murray warn, the potential of health systems to ensure the rights of women and men in equal measure has been challenged by the ongoing shift towards commercialization within the health sector. Koivusalo and Sexton maintain that it is important to distinguish between privatization and commercialization. As they point out, across the world many health care systems are funded through private insurance or through a combination of public financing and private provision of health care. However, as they argue, the crucial issue with respect to commercialization is not just about ownership, but also about the purpose of health systems and how far these are profit-­oriented. It is this shift to commercialization that raises some important concerns that have to date been relatively under-­researched in the health field. As Murray states it is sometimes assumed that certain areas, such as maternal and child health care services, stand outside the reach of commercial activities in developing countries; but as these two chapters show, this is not the case and these processes raise some specifically gendered concerns. Koivusalo and Sexton suggest that there are three ways in which the links between commercialization, health care and the impacts on women can be analysed. The first is uncovering the ways in which more commercialized health systems operate and their gender implications. One example of this discussed in their chapter is the ways in which the commercial aspects of a service tend to be prioritized above the concerns and interests of either workers or patients. This is reflected in a variety of pressures on those working within the health care sector, ranging from workplace terms and conditions to the quality of care. In the UK, zero hours contracts are prevalent in care work, as is work that pays less than the minimum wage. Given that the workforce in the health and caring services is predominantly female, at least in Organisation for Economic Co-­operation and Development (OECD) countries, this points to highly gendered inequalities that can occur as a direct result of commercialization. The second issue that the authors suggest requires further exploration is by focusing on specific areas where commercialization of services has become more prominent within publicly or privately financed parts of health care systems, and how these relate to women. Discussion within the chapter particularly highlights the rise of cosmetic surgery, most notably among women. Finally there is a need to look at how demand and supply for services is created, including new areas and ‘needs’ for medical and health care beyond what is currently provided. One example of this considered within the chapter is the rise of caesarean sections among women in a large number of geographical settings. This is a concern also taken up by Murray, who considers a range of explanatory factors for this growth. Murray’s chapter also reflects on other areas for concern, including the continuing expansion of ‘partnerships’ between the public sector and corporate actors which has taken a number of different forms in the area of maternal and child health. While links with the private sector are not necessarily new in themselves, one aspect that is particularly troubling, according to Murray, is the unquestioning acceptance of these relationships without due consideration to the potentially problematic elements of these

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Gender and health: an introduction  ­15 ‘partnerships’ and what they really mean for advancing the health needs of women and children – rather than the commercial interests of corporate actors. Focusing on a rather different context in Chapter 20, Sarah Ssali, Sally Theobald, Justine Namakula and Sophie Witter reflect on how far gender equity is considered and realized in the reconstruction of the health sector in post-­conflict settings. Their analysis considers the case of Northern Uganda, which has experienced multiple conflicts and a reconstruction process that has been in place since 2007. As the authors suggest, the post-­conflict trajectory presents an opportunity to rebuild health systems to better meet the needs of all citizens, yet in reality little gender analysis has occurred. Instead their analysis found that reconstruction efforts were dominated by attention to maternal and child health (MCH) in health service provision and health system reconstruction and strengthening, regardless of whether such actors were government or non-­government. This focus informed the nature of facilities constructed, the services provided and the indicators on which performance was measured. Yet as their chapter shows, while MCH is clearly important this type of approach fails to acknowledge that women’s – and indeed men’s – health needs go beyond the MCH agenda, and in a post-­conflict setting it is particularly important to consider how these needs are shaped by other factors, especially poverty, age and life course. The chapter also highlights the importance of using a ‘gender lens’ to understand the needs of health workers. As the authors argue, health workers’ experiences and expectations are mediated by gender, as are experiences of conflict, and need consideration to support health care workers and enable them to deliver in their vital roles. In Chapter 21, Johanna Gonçalves Martín examines the promotion of intercultural approaches to health where efforts have been made to integrate the needs of indigenous communities into health systems. Her work draws on her experiences of working as both a doctor and an anthropologist with the Yanomami people in Venezuela. Her analysis points to the inherent tensions between hegemonic biomedical models of ‘safe motherhood’, which even in remote, rural areas advocate the need for women to be close to a health post where some form of medical intervention can occur if required, and the birthing and childrearing practices advocated by indigenous groups such as the Yanomami people. As Gonçalves Martín explains, within these communities women prefer to give birth on their own and will only invite an older woman to attend the birth if some kind of problem is anticipated. Where there is a real risk to the child or mother a shaman rather than a midwife or doctor will be called upon to intervene, and doctors will only be brought in on rare occasions. In some instances women have had to give birth in hospital, and Gonçalves Martín shows how language and cultural barriers can mean that women’s immediate needs are rarely met. Yet, as she argues, these experiences point to the shortcomings of the Venezuelan health system to fully acknowledge an alternative ontology of well-­being and reproduction, in spite of recent changes in both reproductive health care policies and policies for indigenous peoples’ health, including those advocated within the global health discourse such as that put forward in Cairo in 1994.

HOUSEHOLDS, HEALTH AND HEALTHCARE One area of concern that has emerged from the feminist economics and gender and development literature that has gradually been incorporated into health debates is the need to

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16  Handbook on gender and health look more closely at the role of households in both the production and the consumption of health care. Yet despite insights from feminist research into intra-­household decision-­ making processes and the allocation of resources, health policies, most notably financing strategies, often contain implicit assumptions about the unitary nature of households, and that resources are equally allocated among all members of the household. Attention is rarely given to the complexities of intra-­household relations and family structures in the design and implementation of health policies. However, research for example on the gendered impacts of out-­of-­pocket payments and user fees suggests that they tend to impact more negatively on women than men (Ewig and Bello, 2009; Tibandebage and Mackintosh 2010) and points to the need for more nuanced understandings of how decision-­making processes operate within households and what this might mean for health and well-being. The intergenerational transfer of poor health-­ related behaviours is considered in Part VI, Chapter 22 where Karen Devries, Heidi Grundlingh and Louise Knight examine the question of children’s exposure to violence in gendered social contexts. One of the main risk factors for experience of violence as an adult is prior experience of violence as a child, and therefore their chapter reviews the debates that have sought to explain these cycles of violence and reflect on the physical and mental health implications of these processes. As the authors argue, individual pathways into violence need to be considered within a broader context and it is important to acknowledge the ways in which this is shaped by gender. Different attitudes and behaviours are seen as acceptable and normative for men versus women; for example, hegemonic masculinities which ‘allow’ adolescent men to have poor emotional regulation and behave aggressively, while young women are frequently expected to be more passive and are often ‘blamed’ for men’s aggressive behaviour where they have transgressed feminine norms. Their chapter also considers some intervention strategies which in certain settings have produced positive results for change. In Chapter 23 Rachel Tolhurst, Esther Richards, Eleanor MacPherson, Dorcas Kamuya, Flavia Zalwango and Sally Theobald take up the issue of intra-­household decision-­making and use a small number of case studies to explore the complexities of households. Their analysis points to the fact that household structures are many and varied and that there is a need to understand how gender and generation shape decision-­ making capacities within and beyond households. The case studies also illustrate the ways in which bargaining positions are dynamic and constantly (re)constructed through cumulative effects of decisions made over time, and how they are also underpinned by a number of variables including access to material resources and social networks. Their work particularly highlights the importance of taking a longer-­term view since their study clearly illustrates how constrained capacities at one point in the life course contributed to shaping the conditions for weaker breakdown positions at later stages.

GENDER, SOCIAL ACTIVISM AND HEALTH A large body of literature has explored the potential for change offered by grassroots activism in the health sector, and a significant body of authors have considered the gender dimensions of these debates (Doyal and Pennell, 1979; Gideon, 2014; Petchesky,

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Gender and health: an introduction  ­17 2003; Turshen, 1991). Some discussion has centred around the nature of the spaces that exist for people’s activism and the extent to which they are top-­down ‘invited spaces’, or ‘popular spaces’ where people come together at their own instigation (Cornwall, 2004; Cornwall and Coelho, 2007). While women have played an important role in health activism it is also important to recognize that not all women’s health activism has a feminist agenda (Molyneux, 2001). This is certainly the case among the multitude of women’s organizations mobilizing around diverse dimensions of health, although many ultimately have a shared agenda of getting their voices and needs recognized in policy debates (Doyal, 1996). The two chapters in Part VII provide contrasting examples of attempts to incorporate citizens’ voices into policy debates and discussions around health issues, at the national level in the case of Chapter 24, and at the global level as discussed in Chapter  25. Significantly, while activism around health has often been seen as part of women’s traditional ‘community role’, Sara Smith and Marcia Inhorn in Chapter 25 show how men are also actively engaging with health-­related concerns and seeking new ways of pushing for better health outcomes for men. In Chapter 24, Jeannie Samuel examines a rights-­based participatory governance initiative in the southern Andean region of Puno, Peru which uses citizen monitors to ensure the effective functioning of public sector reproductive health services. The citizen monitors are mainly indigenous, Quechua-­speaking women who have long experienced discrimination and exclusion in Peruvian society. The initiative draws on ideas around active citizenship, human rights advocacy, participatory democracy and vigilancia ciudadana, a national reform movement for citizen monitoring in Peru. While the programme does offer some cause for optimism, given the positive results it has produced, Samuel also expresses caution since the ability of monitors to address the wider systemic issues that they identify remains highly limited, particularly in the context of neoliberal models of health reforms. A more global example of citizen activism is offered in Chapter 25 by Smith and Inhorn, who examine the ways in which men are enacting emergent masculinities – or new ways of being a man that run counter to forms of hegemonic manhood – through their participation in the Movember Movement. The Movember Movement is a global organization that encourages men to grow and stylize a moustache every November, with the aim of raising awareness and funding around men’s health issues, notably prostate cancer, testicular cancer and mental health. As the authors argue, a moustache is something that is frequently seen as a symbol of hegemonic masculinity, but by encouraging men to playfully stylize their moustache, the Movember Movement hopes to also challenge the ways in which men think about their own health. The chapter reflects on the ways in which the Movement has been able to achieve its objectives and what this can contribute to work and understandings around health and masculinity.

GENDER, HEALTH, SEXUALITY AND RIGHTS Finally, Part VIII of the book brings together a set of chapters that engage with debates and discussions around gender, health, sexuality and rights. As Matthew Gutmann reflects in Chapter 26, men have been notably absent from debates around gender and health, particularly discussion around male heterosexuality and r­eproduction.

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18  Handbook on gender and health As he reflects, the lack of cross-­cultural analysis around men’s sexuality ‘can lead us blithely to assume that . . . we know what most men are like with respect to sexuality and reproduction’. Nevertheless, as he suggests, the challenge is how to incorporate men into these debates without losing sight of the politics of reproduction. Indeed, as he notes, many feminist theories of gender inequality as well as insights from queer theory have been critical in developing analysis around men, sexuality, reproduction and masculinity. His chapter challenges many of the widespread assumptions that have become embedded in much health discourse and which contribute to prevalent ideas around men’s oppressive forms of behaviour. These include men’s apparent lack of responsibility for birth control, yet as Gutmann’s work in Mexico clearly ­demonstrates these kinds of beliefs fail to acknowledge the active participation and empathy of any men in contraception. Gutmann argues that the involvement of men in contraception is not just a matter of individual choice or a question of how far macho cultures affect the take-­up of male forms of contraception. As he suggests, in order to challenge what has been termed the ‘female contraceptive culture’, in which women worldwide are overwhelmingly responsible for birth control, we also must look at the role of a wide range of global and state-­level actors including governments, donor agencies, the Catholic Church and pharmaceutical companies in the promotion of population control, family planning, and reproductive health and sexuality campaigns. However, as chapters by Lynn Morgan and Gabriela Alvarez Minte clearly demonstrate, women’s rights within this female contraceptive culture are frequently challenged and under threat from many of these global and state-level actors. In Chapter 27, Lynn Morgan documents the appropriation of human rights discourses by conservative Catholics in Latin America. The starting point for her investigation was the awarding of a human rights prize – the Rosa Parks Prize for Citizenship in Defence of Human Rights – to an Argentine pro-­life, conservative Senator, Liliana Negre de Alonso. Indeed as Morgan comments, Rosa Parks and Negre de Alonso are ‘unlikely bedfellows’. Yet as Morgan shows in her chapter, the award is part of a widespread effort by conservative Roman Catholic activists to appropriate the liberal language of human and civil rights and use it to advance pro-­family, pro-­life agendas across Latin America. To date little attention has been given to the ways in which conservative Catholics are co-­opting the conceptual framework of human rights to promote their political agendas, and her chapter addresses this critical knowledge gap. Morgan’s chapter shows how efforts by conservative Catholics have gained ground across the region. Nevertheless, as Morgan argues, their approach seeks to ‘essentialize Latin America’ and fails to engage with much of the reality of the region, including that for many ‘human rights derive not from liberal legal traditions or abstract moral standards, but from the tension between repressive regimes and social justice movements’. Moreover, despite the strong influence of Catholicism across the region, social trends are changing and Latin America has some of the highest contraceptive prevalence and abortion rates in the world; as Morgan argues, ‘there are reasons to doubt the correspondence between doctrine and behaviour’. The backlash against women’s sexual and reproductive rights is also examined in Gabriela Alvarez Minte’s analysis of Chile in Chapter 28. Her work focuses on three key areas relating to sexual and reproductive health and rights: abortion, sexual education in

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Gender and health: an introduction  ­19 schools and access to emergency contraception. The Committee on the Elimination of Discrimination against Women (CEDAW) has expressed concern since the mid-­1990s about the lack of access to contraception in Chile; the high rates of teenage p ­ regnancies – allegedly closely linked to the quality of sexual education; and particular concern about the illegality of abortion regardless of the circumstances. In order to understand the backlash and resistance to rights in these areas Alvarez Minte examines developments in the legislative arena, focusing on the ways in which specific policies and laws have been negotiated, and then considers how far they are – or are not – implemented and transformed into access to services and women’s and men’s choices in matters of reproduction. Her analysis shows how pervasive the power of the Catholic Church can be in Chile as she maps out the ways in which different sets of actors, including from the Church, have attempted to promote and constrain rights in the three areas over the past few decades. Even once women’s reproductive rights have been guaranteed in law, such as the passing of legislation in 2010 guaranteeing the provision of emergency contraception in public health centres to any woman over 14 years of age requesting it, the influence of the Church has remained apparent. In this instance strong links between sectors of the business elite and elements of the Catholic Church became very clear as three of the most significant national chains of pharmacies refused to stock emergency contraception despite previously selling it. Yet as Chapter 29 by Marianna Leite demonstrates, even where governments adopt human rights language and appear to promote rights-­based approaches, gaps between rhetoric and reality remain. Her analysis of the Brazilian case shows how feminist groups were able to push for a particular understanding of women’s health during the transition to democracy, and this was integrated into the women’s health programmes of the new democratic government. Nevertheless while subsequent administrations co-­opted the discourse, they failed to deliver on more equitable outcomes in relation to women’s health; this is particularly evident in high maternal mortality rates, especially among low-­income black women. In Chapter 30, Jorge Lyra and Benedito Medrado also focus on the case of Brazil and reflect on how men have been excluded from the conceputalization of reproductive rights as well as the accompanying policy process  in  Brazil. Through a series of interviews and analysis of policy documents they look at men’s absence from these processes and consider some future pathways for change. In a very different geographical context Benjamin Eveslage’s Chapter 31 reflects on the practical and theoretical tensions that can arise when global development actors seek to introduce rights-­based frameworks, particularly around sexual and reproductive health and rights. Many international development donors have avoided working on sexual rights, given the difficulties of ‘operationalizing’ them and because these rights are often not fully understood by policy actors. Moreover, donors seek to promote their own understandings of sexual rights which can fail to acknowledge locally defined ideas around sexual rights and sexuality, thus leading to tensions. Since 2011 a growing number of Western governments have supported lesbian, gay, bisexual, transgender (LGBT) rights as a foreign policy objective, and the United Nations began advocating for the human rights of people discriminated against based on their sexual orientation or gender identity. Drawing on empirical data from Ghana, Eveslage’s chapter highlights a number of complex tensions that have arisen as a consequence of donor interventions around

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20  Handbook on gender and health sexual health and sexual rights. His analysis shows how donors opted to work with local Ghanaian non-­ governmental organizations (NGOs) with access to sexual minority groups, given their history of advocacy work, yet donor funds prioritized work around HIV/AIDS awareness and prevention. These NGOs were then limited in the work they could do to promote human rights. Thus, as a consequence of their engagement with donors funding HIV interventions, the mandates of these NGOs shifted from one promoting sexual rights to an emphasis on sexual health that better fitted donor priorities. Eveslage argues that this shift has set back efforts to advance sexual rights in Ghana in a number of ways. The Handbook closes with Chapter 32 by Lesley Doyal which examines the ways in which HIV positive women struggle (with varying degrees of support) both to survive and to live up to their own and other people’s expectations of motherhood. As her chapter demonstrates, while knowledge around the ‘prevention of mother to child transmission’ (PMTCT) has expanded considerably and the needs of children are frequently the primary focus of policy interventions, the needs of positive mothers are often overlooked, particularly in the early post-­partum period. Doyal examines the experiences of HIV positive women in the Global South, who have to negotiate the reality of pregnancy (whether intended or unintended) with or without anti-­retroviral therapy. Her analysis highlights the complex social, economic and cultural constraints on their lives as they face the twin challenges of HIV and pregnancy with few resources at their disposal. As she argues, despite numerous challenges, some progress can be made by integrating and expanding HIV and sexual and reproductive health services that are designed with the particular needs of positive women in mind. In conclusion, the chapters presented within this Handbook clearly point to the need to move beyond reluctant attempts to ‘mainstream’ gender, but instead engage with more nuanced and reflective means of understanding more thoroughly the gendered pathways into poor health and ways of promoting better health outcomes for all. The volume seeks to highlight different disciplinary approaches and perspectives for a gendered analysis of health and underlines the importance of additional empirical data to support work in this area. In sum, the book offers critical insights into developing a clear road map that will take us closer towards achieving gender justice in health.

REFERENCES Anderson, J. (2006) ‘Reflections on the social determinants of women’s health. Exploring intersections: does racialization matter?’, Canadian Journal of Nursing Research, 38 (1): 7–14. Barker, G., Ricardo, C. and Nascimento, M. (2007) Engaging men and boys in changing gender-­based inequity in health: evidence from programme interventions, WHO: Geneva. Available at http://www.who.int/gender/ documents/Engaging_men_boys.pdf, accessed 13 July 2015. Chant, S. and Sweetman, C. (2012) ‘Fixing women or fixing the world? “Smart economics”, efficiency approaches and gender equality in development’, Gender and Development, 20 (3): 517–529. Connell, R. (2012) ‘Gender, health and theory: conceptualizing the issue, in local and world perspective’, Social Science and Medicine, 74: 1675–1683. Cornwall, A. (2004) ‘Introduction: new democratic spaces? The politics and dynamics of institutionalized ­participation’, IDS Bulletin, 35 (2): 1–10. Cornwall, A. and Coelho, V.S. (2007) ‘Spaces for change? The politics of participation in new democratic arenas’, in Cornwall, A. and Coelho, V.S. (eds), Spaces for Change? The Politics of Participation in New Democratic Arenas, London, UK and New York, USA: Zed Press.

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Gender and health: an introduction  ­21 Cornwall, A., Harrison, E. and Whitehead, A. (2007) ‘Gender myths and feminist fables: the struggle for interpretive power in gender and development’, Development and Change, 38 (1): 1–20. Crenshaw, K.W. (1991) ‘Mapping the margins: intersectionality, identity politics, and violence against women of color’, Stanford Law Review, 43 (6): 1241–1299. Doyal, L. (1995) What Makes Women Sick? Gender and the Political Economy of Health, Basingstoke and London: Palgrave Macmillan. Doyal, L. (1996) ‘The politics of women’s health: setting a global agenda’, International Journal of Health Services, 26 (1): 47–65. Doyal, L. and Pennell, I. (1979) The Political Economy of Health, London: Pluto Press. Ewig, C. (2010) Second-­Wave Neoliberalism: Gender, Race and Health Sector Reform in Peru, University Park, PA: Pennsylvania State University Press. Ewig, C. and Bello, A.H. (2009) ‘Gender equity and health sector reform in Colombia: mixed state–market model yields mixed results’, Social Science and Medicine, 68: 1145–1152. Freedman, L.P., Waldman, R.J., de Pinho, H., Wirth, M.E., Mushtaque, A., Chowdhury, R. and Rosenfield, A. (2005) ‘Transforming health systems to improve the lives of women and children’, Lancet, 365: 997–1000. Gideon, J. (2012) ‘Engendering the health agenda? Reflections from the Chilean case, 2000–2010’, Social Politics, 19 (3): 333–360. Gideon, J. (2014) Gender, Globalization and Health in a Latin American Context, Basingstoke, UK and New York, USA: Palgrave Macmillan. Gilson, L. (2003) ‘Trust and the development of health care as a social institution’, Social Science and Medicine, 56: 1453–1468. Goetz, A.M. (1997) ‘Introduction: getting institutions right for women in development’, in Goetz, A.M. (ed.), Getting Institutions Right for Women in Development, London, UK and New York, USA: Zed Press. Greco, G., Powell-­Jackson, T., Borghi, J. and Mills, A. (2008) ‘Countdown to 2015: assessment of donor assistance to maternal, newborn, and child health between 2003 and 2006’, Lancet, 371: 1268–1275 Gutmann, M. (2006) The Meanings of Macho: Being a Man in Mexico City, Berkeley, CA: University of California Press. Hawkes, S. and Buse, K. (2013) ‘Gender and global health: evidence, policy, and inconvenient truths’, Lancet, 381: 1783–1787. Hoedeman, R. (2011) ‘Is our healthcare system able to broaden the scope? Response to How should we Define Health? Huber et al.’, BMJ, 343: d4163. Hsu, J., Berman, P. and Mills, A. (2013) ‘Reproductive health priorities: evidence from a resource tracking analysis of official development assistance in 2009 and 2010’, Lancet, 381: 1772–1782. Inhorn, M.C. (2006) ‘Defining women’s health: a dozen messages from more than 150 ethnographies’, Medical Anthropology Quarterly, 20 (3): 345–378. Inhorn, M.C. (2012) The New Arab Man: Emergent Masculinities, Technologies, and Islam in the Middle East, Princeton, NJ: Princeton University Press. Inhorn, M.C. and Whittle, K.L. (2001) ‘Feminism meets the “new” epidemiologies: toward an appraisal of antifeminist biases in epidemiological research on women’s health’, Social Science and Medicine, 53 (5): 553–567. Kuhlmann, E. and Annandale, E. (2010) ‘Bringing gender to the heart of health policy, practice and research’, in Kuhlmann, E. and Annandale, E. (eds), The Palgrave Handbook of Gender and Healthcare, Basingstoke, UK and New York, USA: Palgrave Macmillan. Larson, J. (1999) ‘The conceptualization of health’, Medical Care Research and Review, 56 (2): 123–136. Mackintosh, M. and Tibandebage, P. (2006) ‘Gender and health sector reform: analytical perspectives on African experience’, in Razavi, S. and Hassim, S. (eds), Gender and Social Policy in a Global Context: Uncovering The Gendered Structure of ‘The Social’, Basingstoke: Palgrave. MacPherson, E., Richards, E., Namakhoma, I. and Theobald, S. (2012) ‘Dimensions of gender equity in health in East and Southern Africa’, Equinet Discussion Paper 90. Available at http://www.equinetafrica.org/bibl/ docs/Diss90%20Gender%20Equity%20May2012.pdf, accessed 12 January 2016. Marmot, M., Friel, S., Bell, R., Houweling, T.A.J. and Taylor, S. (2008) ‘Closing the gap in a generation: health equity through action on the social determinants of health’, Lancet, 372: 1661–1669. Molyneux, M. (2001) Women’s Movements in International Perspective: Latin America and Beyond, Basingstoke, UK and New York, USA: Palgrave Macmillan. Molyneux, M. (2006) ‘Mothers at the service of the New Poverty Agenda: Progresa/Oportunidades, Mexico’s conditional transfer programme’, Social Policy and Administration, 40 (4): 425–449. Pannenborg, C. (1979) A New International Health Order: An Inquiry into the International Relations of World Health and Medical Care, Alphen aan den Rijn, The Netherlands: Sijthoff & Noordhoff. Payne, S. (2014) ‘Gender mainstreaming as a global policy paradigm: barriers to gender justice in health’, Journal of International and Comparative Social Policy, 30 (1), 28–40. DOI: 10.1080/21699763.2014.886609. Payne, S. and Doyal, L. (2010) ‘Re-­visiting gender justice in health and healthcare’, in Kuhlmann, E. and

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22  Handbook on gender and health Annandale, E. (eds), The Palgrave Handbook of Gender and Healthcare, Basingstoke, UK and New York, USA: Palgrave Macmillan. Petchesky, R. (2003) Global Prescriptions: Gendering Health and Human Rights, London: Zed Books. Pitt, C., Greco, G., Powell-­Jackson, T. and Mills, A. (2010) ‘Countdown to 2015: assessment of official development assistance to maternal, newborn, and child health, 2003–08’, Lancet, 376: 1485–1496. Razavi, S. (2012) ‘World Development Report 2012: gender equality and development – a commentary’, Development and Change, 43 (1): 423–437. Sen, G. and Östlin, P. (2009) ‘Gender as social determinants of health: evidence, policies and innovations’, in Sen, G. and Östlin, P. (eds), Gender Equity in Health: The Shifting Frontiers of Evidence and Action, London, UK and New York, USA: Routledge. Standing, H. (1997) ‘Gender and equity in health sector reform programmes: a review’. Health Policy and Planning, 12 (1): 1–18. Tibandebage, P. and Mackintosh, M. (2010) ‘Maternal mortality in Africa: a gendered lens on health system failure’, Socialist Register, 46, 168–183. Turshen, M. (1991) Women and Health in Africa, Trenton, NJ: Africa World Press. UN Women (2010) Gender justice: key to achieving the Millennium Development Goals. Available at http:// www.unwomen.org/~/media/headquarters/media/publications/unifem/unifemmdgbrief2010.pdf, accessed 27 August 2015. WHO (1948) ‘WHO definition of health’, Available at http://who.int/about/definition/en/print.html, accessed 22 December 2015.

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PART II GENDER, HEALTH AND PUBLIC POLICY

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2.  Agenda-setting in women’s health: critical analysis of a quarter-­century of paradigm shifts in international and global health Ramya Kumar, Anne-­Emanuelle Birn and Peggy McDonough

In recent years a range of international health and development agencies1 have reasserted their commitment to addressing women’s health in low-­and middle-­income countries (LMICs).2 This renewed attention to maternal and child health (MCH) and family planning departs from the broader 1990s emphasis on reproductive health, drawing instead from prior MCH approaches entrenched in colonial exigencies and neocolonial population control strategies. These distinct understandings of women’s health have been driven by a shifting mix of nation-­building politics, ideological and foreign policy interests, corporate agendas, and the advocacy efforts of diverse women’s groups (AbouZahr, 2001; Birn, 1999; Wilson, 2015). The politics of agenda-­ setting in international/global health3 (Navarro, 1999) are veiled by humanitarian discourses and rhetorical attention to (gender and) health equity. Geopolitics remains largely unacknowledged in efforts that seek solutions for problems assumed to be shared by the world’s population (see Koplan et al., 2009). Most global health endeavours are constrained by a paternalistic donor-­driven framework through which governments of high-­ income countries, multilateral/bilateral agencies, and/or philanthropic foundations influence agenda-­setting in the Global South (Birn et al., 2009),4 overlooking the everyday experiences of people (Biehl and Petryna, 2013). The underplaying of power relations is highly pertinent to the field of women’s health where the objective of ‘saving women’ eclipses the political and economic dimensions of interventions, which are often framed in altruistic terms (Wilson, 2015). This chapter analyses and contextualizes the trajectory of the dominant international women’s health agenda over the past-­quarter century. This agenda encompasses the numerous policy-­making initiatives and advocacy efforts undertaken by international health and development agencies – sometimes informed by transnational women’s rights groups – that target policies, programmes and services relevant to women’s health in the Global South. The chapter begins by examining the key historical antecedents that gave rise to contemporary understandings of (international) women’s health. We then explore the social, political and economic forces and players that have shaped the international women’s health agenda, from the 1994 Cairo and 1995 Beijing conferences and the United Nations (UN) Millennium Project, to the Sustainable Development Goals. We demonstrate how a constellation of actors, including the United States (US) and other powerful states, governments of LMICs, international financial institutions, a range of private entities, and mainstream women’s health advocacy groups shape dominant definitions of, and responses to, women’s health ‘problems’ in the Global South. We suggest that 25 Jasmine Gideon - 9781784710859 Downloaded from Elgar Online at 11/03/2017 02:47:53AM via Sydney University

26  Handbook on gender and health narrowly conceiving women’s health as MCH and family planning aligns with prevailing neoliberal development discourses and transnational interests that in various forms have long shaped international/global health policy. We conclude by supporting an alternative direction for women’s health advocacy that moves beyond its current institutionalized arrangement to forging coalitions with grassroots social justice movements in search of a radical post-­2015 women’s health agenda.

THE POST-­WAR MAKING OF AN INTERNATIONAL WOMEN’S HEALTH AGENDA The internationalization of efforts to advance women’s health can be traced to the creation of the UN system in the mid-­1940s when new and revamped international development agencies unified efforts to address MCH. Yet the question of maternal health and reproduction had been central to nationalist, state-­building and imperial aspirations long before this. With the rise of the modern nation-­state, a healthy and growing population became a symbol of national power and essential to the exercise of military might. It ensured a viable workforce that was as relevant in early industrial and plantation/colonial settings as it is today. This interest in population is evidenced in burgeoning MCH policies of the late nineteenth and early twentieth century in settings as distinct as Brazil, Puerto Rico, France, colonial Vietnam, Ceylon and Canada (Briggs, 2002; Comacchio, 1993; De Barros, 2014; Jones, 2004; Manderson, 1992; Nguyen, 2010). In the first half of the twentieth century, the principles, policies and practices around reproduction and MCH were largely circumscribed to national or intra-­imperial contexts. Concerns with improving the population stock through coercive sterilization, marriage restrictions and incentives for healthy coupling, reproduction and childrearing were intertwined with public health’s expanding purview (Bashford and Levine, 2010). Meanwhile, international efforts such as the Rockefeller Foundation’s disease campaigns and institution-­building efforts addressed MCH, but in incidental and instrumental ways. Likewise, despite early twentieth-­ century requests by Pan American Sanitary Bureau member countries to tackle MCH, the organization resisted doing so for decades, ­acceding only in the face of eugenic anxieties (Birn, 2002). Still, there were certain exceptions that involved varying degrees of international collaboration. For instance, at the League of Nations, middle-­class European feminists and women reformers organized committees and studies in the 1920s on the trafficking of women and children and the causes of infant mortality (Marshall, 1999). A parallel group in the Americas held a series of Pan American Child Congresses that also touched on women’s health in the guise of maternal health (Guy, 1998). Eugenicist groups and women’s associations in the metropolitan centres established links with indigenous elites in a bid to propagate birth control in colonial peripheries (Klausen and Bashford, 2010). For example, Margaret Sanger collaborated closely with Indian eugenicists and women’s advocates, and played an instrumental role in building consensus for the passage of a birth control resolution at the 1935 All India Women’s Conference (Ahluwalia, 2008). The creation of a muscular UN system provided the infrastructure to internationalize MCH. The United Nations International Children’s Emergency Fund (now the United

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Agenda-­setting in women’s health  ­27 Nations Children’s Fund – UNICEF), established in 1946 to look after the needs of ­children displaced and orphaned in World War II, carried the mantle of child health, and, perforce, the health of mothers (WHO, 1958). Promotion of MCH was listed as a function of the World Health Organization (WHO) in its 1948 constitution, and MCH designated a ‘top priority’ along with malaria, tuberculosis, venereal disease, nutrition and environmental sanitation, at the first World Health Assembly (WHO, 1958, 2006). The WHO established expert advisory panels and committees on MCH to provide technical assistance to member states. The main thrust of these activities during the 1950s was to train personnel and provide technical guidance on integrating MCH into national health systems (Campbell, 2001; WHO, 1958). As the Cold War unfolded, international attention to MCH was gradually eclipsed by population anxieties.

FAMILY PLANNING AND COLD WAR POLITICS With the Cold War’s escalation, First World powers began to view the ‘population explosion’ in decolonizing Third World countries as a threat to the Western bloc and to capitalism itself. First World governments, most notably the US, supported the production of demographic evidence that linked Third World underdevelopment to population growth, and stepped up financial assistance for family planning initiatives to stave off communist influence (Hartmann, 1995). The UN distanced itself from the population question until the 1960s because birth control questions had sparked incendiary debates at the League of Nations, and later at the WHO. Instead, philanthropic foundations and international non-­governmental organizations (NGOs) carried forward the population agenda, sustained with support from First World governments. Important among these NGOs were the International Planned Parenthood Federation, the Rockefeller-­affiliated Population Council, the Pathfinder Fund, and the Ford Foundation (Bashford, 2008; Connelly, 2008; Lopez, 2014). In the 1960s, the UN embarked on its first Development Decade (1961–1970) to ­streamline UN activities toward a common goal of social and economic development (WHO, 2008). The UN General Assembly passed a resolution in 1962 to expand its research programme on population and development, marking its official recognition of population as a developmental concern (Finkle and Crane, 1975). Led by John D. Rockefeller III, the ‘population establishment’5 unrelentingly mobilized international actors, including the UN, on the population ‘problem’. Their efforts culminated in the first World Population Conference held in Belgrade in 1965, and then the Declaration on Population, signed by 12 heads of state a year later, paved the way for the creation of a trust fund for population activities (Ayala and Caradon, 1968; Finkle and Crane, 1975). The UN General Assembly and the World Health Assembly officially endorsed providing technical assistance for family planning to member states in 1966, and the trust fund moved to the UN in 1969 to be designated the United Nations Population Fund (UNFPA). The WHO subsequently integrated family planning into MCH under its ‘family health programme’ to align service provision with development needs (Robinson, 2010; WHO, 2008). Although some Catholic nations and socialist regimes resisted the family planning drive, most Third World leaders, preoccupied with intractable poverty and broader economic concerns, accepted the policy (Finkle and Crane, 1975). In India,

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28  Handbook on gender and health for example, coercive family planning policies induced millions to accept long-­acting contraceptive methods or sterilization (Vicziany, 1982). As decolonization movements gained momentum in South Asia, East Asia, Africa and,  later, the Caribbean, the population control regime came under scrutiny. Having united at the 1955 Bandung Conference to demand sovereignty and fair economic relations, the Non-­Aligned Movement6 strengthened and acquired UN representation as the Group of 77 (G-­77) through the 1964 United Nations Conference on Trade and Development (UNCTAD). Building on momentum gained after the 1973 oil crisis, the G-­77 collectively pressed for the implementation of a ‘New International Economic Order’ at the 1974 World Population Conference, and rejected population control as an effective pathway to development (Finkle and Crane, 1975; Gilman, 2015; Prashad, 2012). The shifting balance of power between the Soviet Union and the US, the re-­entry of China to the UN, and a strengthening Non-­Aligned Movement allowed the UN to embrace a more expansive approach to health and development in the 1970s. Pushed by Third World member states, and inspired by China’s ‘barefoot doctors’ and grassroots initiatives elsewhere, the WHO adopted the 1978 Alma Ata Declaration which aspired to ‘Health for All’ by the year 2000 (Baum, 2007; Cueto, 2004; Litsios, 2002). Alma Ata decried inequality and declared health a fundamental human right and an issue of social justice. Its intersectoral approach recognized comprehensive primary health care and community empowerment as key elements of equitable development. Notably, MCH and family planning remained integral components of the new development framework (WHO, 1978, 2008).

EMERGING INTERNATIONAL WOMEN’S HEALTH ADVOCACY The 1970s saw a proliferation of grassroots movements demanding social change across the world. In Latin America, women’s groups led national movements against the ‘disappearances’ of political activists at the hands of authoritarian states7 (Di Marco, 2010; Schirmer, 1993). In India, the Shahada Movement, a landless labourers’ movement, condemned the exploitative practices of landowners; the United Women’s Anti-­Price Rise Front resisted food price hikes; and the Chipko Movement mobilized against deforestation (Kumar, 1995). In North America and Western Europe, women’s liberation movements demanded equal access to economic resources and parity in political representation, while a radical women’s health movement struggled for women’s reproductive rights and freedoms (Annandale, 2009; Meyer, 2003). Amidst the long and diverse history of women’s activism (Basu, 1995), two processes of internationalization widened the reach of women’s movements in the 1970s. First, the institutionalization of women’s rights within the UN and their subsequent affirmation in UN human rights instruments. This process gave legitimacy to women’s concerns, including the right to health, and created space to address them at international fora (Gruskin et al., 2007; Tinker and Jaquette, 1987). Second, the European and North American women’s health movements, legacies of radical ‘second-­wave’ feminism, grew in reach (Cottingham et al., 1997), at times reinforced by the overlapping goals of the population establishment (Hartmann, 1995). These two processes contributed to  the making of a visible and dominant form of transnational women’s rights ­advocacy that ­overshadowed

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Agenda-­setting in women’s health  ­29 counter-­ hegemonic forms of grassroots women’s ­ mobilization (Hartmann,  1995; Wilson, 2015). The institutionalization of women’s rights at the UN took form as women within inter-­governmental organizations struggled to increase women’s representation on the international stage. Their efforts came to fruition with the declaration of 1975 as International Women’s Year, followed by the UN Decade for Women (1976–1985). The goals for the Decade were debated at the 1975 Mexico City Conference on Women, where forging a consensus proved difficult. Briefly, First World delegates emphasized gender equality, while those representing the Third World again gave precedence to the ‘New International  Economic Order’, adopted a year earlier by the UN General Assembly. Tensions between these conflicting agendas diluted the goals of the Decade, which eventually addressed women’s equality vis-­à-­vis peace and development (Burke, 2015; Çağatay et al., 1986; Tinker and Jaquette, 1987). During the Women’s Decade, intergovernmental institutions, national governments and other agencies created various structures and mechanisms to advance women’s status. For instance, within the UN, the existing Branch for the Advancement of Women was reinforced by the creation of two separate structures to promote women’s participation in development initiatives. Special offices were set up within most UN agencies to integrate women into their programmes. In 1979, the UN General Assembly adopted the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), creating a mechanism to hold member states accountable for women’s rights, inclusive of the right to health (Gruskin et al., 2007). Many governments responded by creating Ministries of Women’s Affairs and other institutions to advance women’s status. NGOs addressing women’s concerns proliferated, including those that promoted progressive alternatives for development such as Development Alternatives with Women for a New Era (DAWN) (Tinker and Jaquette, 1987; UN Women, 2000). The internationalization of women’s reproductive health and rights campaigns occurred  not through the UN, but via the European and North American women’s health movements, which made impressive gains in the 1970s, even as they failed to address class and race concerns (Davis, 2003). The historic 1973 Roe v. Wade Supreme Court ruling in the US recognized a woman’s right to abortion (Garrow, 1999), and the National Abortion Campaign in the United Kingdom (UK) successively defeated all existing anti-­ abortion legislation. The European and North American women’s health movements were  officially internationalized with the London launching of the International Campaign for Abortion Rights in 1978. By the 1980s, influenced by Third World women’s movements, the Campaign’s mandate had broadened to address coercive contraception and sterilization (Cottingham et al., 1997). The now international women’s health movement strengthened in the face of events that transpired at the 1984 Mexico City Conference on Population. The US government, headed by Republican President Ronald Reagan, announced cuts to foreign assistance for  family planning and brought into effect the ‘Global Gag Rule’. The latter would forbid  overseas NGOs receiving foreign family planning assistance from Washington to use their funds (whatever the source) for abortion-­ related activities (Crane and Dusenberry, 2004). These developments were met with widespread contestation by women’s groups and the population establishment, including UNFPA, who had shared concerns about the restrictions on women’s reproductive rights (Hartmann, 1995).

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30  Handbook on gender and health The Decade ended with the 1985 Nairobi Women’s Conference where Northern and Southern feminists came together in the context of deteriorating social conditions and a world economic recession. The ‘Forward-­Looking Strategies to the Year 2000’ formulated at the Conference addressed a wide range of issues, including health, employment, education, social services, women’s political representation, and women’s participation in industry and science (Çağatay et al., 1986; UN Women, 2000). Those relevant to health encompassed improving health facilities and services for women, expanding access to water and sanitation, respecting women’s rights to family planning and reducing maternal mortality (Cottingham et al., 1997; Family Care International, 2007). Maternal and reproductive health would dominate the activist agenda in the decades that followed as the international women’s health movement and the population establishment mobilized for reproductive rights. While this focus resonated well with the aspirations of middle-­class women in the Global South (Desai, 2005), maternal health was soon co-­opted by international health and development agencies to further other agendas.

SETTING THE STAGE FOR THE SAFE MOTHERHOOD INITIATIVE Maternal health appealed to international health and development agencies in the 1980s for several reasons. First, maternal mortality had received enormous attention from activists and academics during the United Nations Decade for Women (see Rosenfield and Maine, 1985). Second, ‘safe motherhood’ was less contentious than ‘reproductive health’, and appealed to donors, particularly in the context of the Reagan administration’s new population policy (Finkle and Crane, 1985; Shiffman and Smith, 2007). Third, and perhaps most significant, was the changing political and economic landscape in the West that saw the Keynesian welfare state increasingly eroded by neoliberalism. Endorsed by the Reagan administration in the US and Prime Minister Margaret Thatcher and her Conservative Party in the UK, this ideology touted strong private property rights, deregulation of industry, downsizing and privatization of public services, and trade liberalization to foster entrepreneurship and economic growth. It also influenced the structural adjustment programmes adopted by Third World governments under the tutelage of the World Bank and International Monetary Fund (IMF) (Harvey, 2005). This shift to neoliberalism brought to the helm a changed constellation of actors, and, in international health, led to the rejection of Alma Ata’s emphasis on state-­led comprehensive primary health care (Birn, 2014). The World Bank, with support from the US, superseded the WHO as primary convener of international health. Previously focused on infrastructure projects, the Bank had begun to directly finance social sector efforts in the 1960s (Kapur, Lewis and Webb, 1997). By the 1980s, the Bank had consolidated its role in health sector development, controversially recommending the implementation of user fees (see World Bank, 1987). After the WHO’s 1981 resolution decrying the unethical marketing of breast milk substitutes, and its essential medicines list advocating the use of generic drugs, the US responded to lobbyist pressure, and substantially reduced its WHO dues. The WHO was forced to rely on the World Bank, bilateral/multilateral organizations, and non-­state actors for

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Agenda-­setting in women’s health  ­31 earmarked funds after the World Health Assembly froze the WHO budget in 1982 (Birn, 2014; Brown et al., 2006). A campaign to discredit Alma Ata had been initiated in 1979 by the Rockefeller Foundation in cahoots with the US government and the World Bank. This campaign promoted ‘selective primary health care’ (SPHC), an alternative and circumscribed approach to address health problems, considered more feasible for LMICs. Retreating to the vertical disease paradigm,8 SPHC supported ‘cost-­effective’ technical solutions for tightly defined international health problems, and narrowly addressed MCH and communicable diseases while rejecting Alma Ata’s premise of intersectoral action on the broader determinants of health. Notably implemented through the UNICEF’s Child Survival Campaigns, SPHC promoted a series of quick fixes to improve child health: growth monitoring, oral rehydration therapy, breast feeding and immunization, later reinforced by women’s education, family planning and food supplementation (Cueto, 2004). Similarly oriented, the Safe Motherhood Initiative was launched by the World Bank, WHO and UNFPA in 1987 to address maternal mortality on a global scale (Rosenfield and Min, 2009). While the Bank’s leadership role in this venture signalled its greater involvement in international health activities, the WHO’s collaboration with UNFPA reflected the growing emphasis on family planning in MCH activities (see WHO, 2008). Two ‘cost-­effective’ strategies were prioritized by the Safe Motherhood Initiative: ante-­ natal risk assessment and the training of ‘traditional’ birth attendants. Both were subsequently deemed ineffective for lowering maternal mortality, and later rejected at the 1997 Colombo Safe Motherhood Technical Consultation in favour of emergency obstetric care (AbouZahr, 2001; Rosenfield and Min, 2009). The engagement of NGOs and other private actors in international health activities substantially grew during this period. For instance, the membership of the Safe Motherhood Initiative Interagency Group, initially comprising the World Bank, WHO, UNFPA, the United Nations Development Programme and UNICEF, later extended to the International Planned Parenthood Federation and the Population Council, also reflecting the nexus between maternal health and family planning. The Initiative received funding from contraceptive manufacturer, Pharmacia-­ Upjohn, and was later supported by a Corporate Council established to attract contributions from multinationals (AbouZahr, 2001; Family Care International, 2007). In sum, ‘safe motherhood’ provided a ‘neutral’ ground to garner assistance from a range of actors, including academics and activists working in the area of women’s health, donor agencies and, importantly, the US Republican administration. However, the more ‘radical’ women’s groups remained opposed to the conflation of women’s health with MCH, particularly the exclusion of abortion and reproductive rights from the women’s health agenda (AbouZahr, 2001). Their collective mobilizations for an expanded definition of reproductive health and rights came to fruition in Cairo.

WOMEN’S REPRODUCTIVE HEALTH AND RIGHTS AT CAIRO AND BEIJING The Cairo Program of Action forged at the 1994 International Conference on Population and Development (ICPD) shifted the development agenda (and, by default, the women’s

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32  Handbook on gender and health health agenda) from one that focused narrowly on achieving demographic targets to a broader framework that placed reproductive health and human rights at its centre. Contraception was but one element of a comprehensive package of sexual and reproductive health services located in broader concerns for gender equality and women’s empowerment (Haslegrave, 2013). The ICPD goals were reaffirmed at the 1995 Beijing Women’s Conference, which aimed to advance Nairobi’s Forward-­Looking Strategies that had made little headway since the 1985 Women’s Conference. The Beijing Platform of Action adopted a life-­cycle approach, expanding further the Cairo definition of women’s health, in particular its provisions on sexual and reproductive health (Bunch and Fried, 1996; UN Women, n.d.). The focus on women’s rights at earlier UN conferences on climate (Rio 1992), human rights (Vienna 1993), and then ICPD, Beijing, and the World Summit for Social Development (Copenhagen 1995), reflected the expanding space to advance women’s rights concerns in the 1990s (Bunch and Fried, 1996). Feminist narratives generally attribute this development to transnational women’s activism based on a ‘global’ feminist consciousness that emerged at the end of the UN Decade for Women (see, for example, Antrobus, 2004; Jaquette, 2009; Moghadam, 2012). These accounts, however, frequently underplay the role of powerful states, notably the US government, and the population establishment, including UNFPA, in the Cairo and Beijing negotiations (McIntosh and Finkle, 1995; Garner, 2012). A key explanatory factor is that these UN declarations were adopted after the end of the Cold War. It was a period when the Clinton administration and other Western governments came together to advance a liberal social agenda while simultaneously pursuing privatization, deregulation and other facets of neoliberal globalization (Garner, 2012; Harvey, 2005). The 1990s saw the reach of international financial institutions and supranational trading bodies grow significantly as the World Trade Organization (WTO) was formed, and a host of trade agreements adopted (Harvey, 2005). High on the Clinton administration’s foreign policy agenda was harnessing women’s contributions to economic development and peace-­building. Indeed, Clinton made this clear early on in his presidency when he boosted assistance for family planning and rescinded the ‘Global Gag Rule’, not least to leverage the US feminist and progressive vote (see Garner, 2012; McIntosh and Finkle, 1995). That said, feminist interventions contributed substantially to the Cairo (and Beijing) deliberations. Transnational women’s groups and NGOs led by the US-­based International Women’s Health Coalition (IWHC) mobilized against the growing restrictions on women’s reproductive rights, and demanded attention to the neoliberal policies affecting women’s livelihoods and health (IWHC, n.d.-­a). Nonetheless, in a politically fraught process of consensus-­building, criticisms of structural adjustment fell by the wayside as the ensuing Cairo Programme of Action focused on reproductive health, emphasizing women’s autonomy and reproductive choice (DeJong, 2000; McIntosh and Finkle, 1995). According to critics, the ICPD insufficiently addressed the political and economic dimensions of social inequality, and women’s empowerment, whether in the spheres of health, education or employment, was framed in a circumscribed fashion to align with the agendas of Western governments. Indeed, some suggest that population advocates, led by the UNFPA, co-­opted reproductive rights and health to carry forward its long-­standing agenda, deploying discourses of environmental protection to obscure

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Agenda-­setting in women’s health  ­33 its primary concern with population control (Hartmann, 1995; Nair et al., 2006; Rao, 2004; Wilson, 2015). Cairo’s solutions for the world’s population living in ‘absolute poverty’ under ‘an unfavourable international economic environment’ (UN, 1994: para. 1.2) discounted the need for equitable resource redistribution. Instead, poverty and inequality were framed as problems of population growth even as progressive proposals – including those on agrarian reform and trade restructuring – were overlooked in the implementation process (Hartmann, 1995; McIntosh and Finkle, 1995; Nair et al., 2006). Moreover, the ICPD’s reproductive health framework failed to effectively address unsafe abortion and sexual rights concerns, partly a result of a relentless Vatican-­led campaign against action on these fronts (Berer, 2009; Haslegrave, 2013). Whatever its merits and shortcomings, the Cairo definition of reproductive health that encompassed human rights and women’s empowerment was short-­lived. The UN Millennium Project that followed on its heels would redraw the boundaries of women’s health by relegating it, once again, to the health of mothers.

THE MDGS, MATERNAL HEALTH AND ECONOMIC DEVELOPMENT In a widely criticized closed-­door process led by the Organisation for Economic Co-­ operation and Development (OECD), the World Bank and the IMF, eight ‘visionary’ Millennium Development Goals (MDGs) were adopted by the UN and endorsed by 189 countries to guide international activities until 2015 (Yamin and Boulanger, 2013). Broadly speaking, the MDGs committed UN member states to work towards ending poverty and hunger, achieving universal primary education, promoting gender equality, advancing health (in several sectors), ensuring environmental sustainability and promoting development. Each MDG comprised a set of targets and indicators with mechanisms in place to monitor progress. All eight MDGs had wide-­ranging implications for health, and three addressed health directly: MDG 4 (‘Reduce Child Mortality’), MDG 5 (‘Improve Maternal Health’), and MDG 6 (‘Combat HIV/AIDS, Malaria and Other Diseases’) (UN, 2008). The UN Millennium Project undermined the progress made in Cairo as the incoming George W. Bush administration, together with the Holy See and a few other UN member states, ensured that reproductive health was absent from the original MDGs. In its initial formulation, MDG 5 aimed to reduce maternal mortality by three-­quarters, and included two monitoring indicators: the maternal mortality ratio and the proportion of births attended by skilled health personnel. Reproductive health was introduced as a target of MDG 5 only in 2007, in response to sustained activism by UNFPA and transnational women’s advocacy groups (Yamin and Boulanger, 2013). In its final version, MDG 5 aimed to reduce maternal mortality by three-­quarters and achieve universal access to reproductive health, by 2015 (UN, 2008). The MDGs have been critiqued at several levels, in particular for relying on an overly technocratic and neoliberal approach to development (see Amin, 2006; Reddy and Heuty, 2008). This was exemplified in MDG 5’s monitoring indicators: three (of four) indicators listed under the reproductive health target9 narrowly focused on expanding access to

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34  Handbook on gender and health contraception, measured by the contraceptive prevalence rate, adolescent birth rate and the unmet need for family planning10 (UN, 2008). While MDG 5 was instrumentally positioned as a means to achieving economic development (see World Bank, 2006), it did not address women’s empowerment,11 so crucial to women’s contraceptive decision-­making. Although attention to reproductive health was in itself laudable, critics argue that such tightly defined targets and indicators served to limit the scope of development assistance while opening markets for health technologies and services in the Global South (Nair et  al., 2006; Waitzkin, 2011). Moreover, the MDGs assumed ‘equitable’ development could be achieved through a model that also endorsed privatization, deregulation and a free market regime (Amin, 2006; Waitzkin, 2011).

PRIVATIZATION OF GLOBAL HEALTH? In recent years, private actors have gained significant influence in agenda-­setting as key financers of the global health industry. For example, H8, a group of powerful health organizations formed in 2007, comprises the WHO, UNICEF, UNFPA, the Joint United Nations Programme on HIV/AIDS (UNAIDS), the Bill and Melinda Gates Foundation (BMGF), the World Bank, and two public–private partnerships (PPPs): the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and the Global Alliance for Vaccines and Immunizations (GAVI Alliance), both launched with BMFG funding. The H8 holds meetings, like the G-­8, at which the mainstream global health agenda is shaped behind closed doors, and organizations considerably influenced by Gates and the BMGF, constitute a majority (Birn, 2014). Global health PPPs are a manifestation of this shift toward the private sector, as relevant  in women’s health as in any other area. For instance, the 2005 Partnership for Maternal, Newborn and Child Health (PMNCH), created to accelerate progress on MDGs 4 and 5, united the efforts of three major global MCH initiatives. The PMNCH comprises the WHO’s Partnership for Safe Motherhood and Newborn Health (derived from the Safe Motherhood Initiative), the UNICEF’s Child Survival Partnership, and Save  the Children’s Healthy Newborn Partnership. The PMNCH’s members include, among others, the BMGF, the MacArthur Foundation and the Johnson & Johnson Corporate Citizenship Trust (WHO, 2015). Similarly, the Family Planning 2020 ­partnership, forged in 2012 to improve women’s access to contraception under the co-­sponsorship of the BMGF, UNFPA and the UK and US governments, receives funding from a wide representation of private actors, including Big Pharma (for example, Merck, Pfizer and Bayer) and the population establishment (for example, the International Planned Parenthood Federation, Population Services International, Marie Stopes International and the Population Council) (FP2020, 2014). Global health PPPs generally seek to expand access to selected ‘cost-­effective’ health technologies and services. For instance, since its inception in 2002, programmes supported by the GFATM have largely focused on vertical programmes to deliver antiretroviral therapy, tuberculosis testing and insecticide-­treated mosquito nets (GFATM, 2016). Improving access to health technologies and services is essential, yet addressing the social conditions that foster the spread of the diseases supported by the GFATM is equally important, and sadly neglected (see Farmer, 2005). Similarly, the Family Planning 2020

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Agenda-­setting in women’s health  ­35 partnership works toward ‘[enabling] 120 million more women and girls to use contraceptives by 2020’, with far less consideration to the social context in which women use contraception (FP2020, 2015). Needless to say, partnering with governments of LMICs opens up new markets for multinationals, while PPPs provide opportunities for displays of ‘corporate social responsibility’ (Birn, 2014; Waitzkin, 2011). At present, a major proportion of development assistance for health, whether from bilateral and multilateral agencies or philanthropic foundations, is channelled through PPPs, also raising questions around conflicts of interest (Adams and Martens 2015). While harnessing contributions from the private sector to achieve ‘universal health coverage’ has been hailed by international health and development agencies and global health policy-­makers (see Fried et al. 2013), many observers are concerned that government health programmes are being dismantled and underfunded (Lo, 2008; Ravindran, 2011; Sengupta, 2013).

THE DIRECTION OF TRANSNATIONAL WOMEN’S HEALTH ADVOCACY AND ITS CO-­OPTATION In the preceding sections, we highlighted the ways in which international health and development agencies have acted on the purported goal of advancing women’s health. Women’s own struggles, at times responding to mainstream interventions, have in turn contributed toward containing women’s health advocacy to the realms of MCH and reproduction. Transnational advocacy on reproductive health and rights has chiefly relied on the UN human rights machinery, in particular, the International Convention on Economic, Social and Cultural Rights, in effect since 1976, and CEDAW, in effect since 1981 (see Cottingham et al., 2010; Gruskin et al., 2008). This form of health advocacy has successfully drawn international attention to specific women’s health issues and facilitated the introduction of mechanisms to redress them as evidenced, for instance, in the recognition of maternal health as a human right (Mesquita and Kismödi, 2012). However, such advocacy efforts have not been able to sufficiently challenge broader social and economic forces, including shrinking welfare budgets and the prevailing free market regime that have widened social and health inequalities since the 1980s (see Gideon, 2014; Jaggar, 2002; McDonough et al., 2013; Wamala and Kawachi, 2007). This situation has been compounded by changes in women’s mobilization strategies. Some suggest that the institutionalization of women’s rights within state structures and institutions of global governance and the broader ‘NGOization’12 of women’s movements have diluted many of the more radical goals espoused by organized women’s groups in the late twentieth century (Alvarez, 1999; Desai, 2005; Menon, 2004). NGOs representing women’s concerns in the Global South have become the recipients of substantial funding from international NGOs, bilateral agencies and private foundations. Access to power and resources has sometimes meant a shift in women’s organizing from community-­based collectives to professional NGOs. In this context, much militant grassroots activism has been replaced by NGO-­based advocacy efforts, generally limited to signature campaigns, petitions and appeals to the state or supranational bodies (Lebon, 2010; Menon, 2004). This trend manifests in the heightened visibility of dominant and institutionalized forms

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36  Handbook on gender and health of women’s health and rights activism that have, at times, rendered invisible counter-­ hegemonic women’s mobilizations (Wilson, 2015). The question of representation has vexed transnational women’s activism for decades (Spivak, 1988). Women’s health concerns, including those of the ‘downtrodden’, are generally represented at international fora by middle-­class women who speak the language of NGO-­based advocacy (Desai, 2005). On the other hand, the women’s health interventions debated and formulated at these fora target a different kind of woman, the ‘Third World Woman’ (Mohanty, 1991), likely black or brown (and perhaps veiled), whose reproductive system preoccupies global actors and institutions. Yet, these very women are excluded from policy-­making fora at the UN and activist venues alike (Desai, 2005; Spivak, 1996: Wilson 2015). In the meantime, right-­based approaches have been co-­opted by powerful states and international donors who appropriate the language of women’s rights to bring attention to selected ‘women’s issues’ (for example, family planning, maternal health, female genital cutting/mutilation, violence against women) that align with their own agendas (see Grewal, 1999; Wilson, 2015). These actors ostensibly support pre-­defined women’s reproductive health concerns while creating the very conditions that exacerbate social inequality. For example, the World Bank spearheads the Global Financing Facility in support of the UN’s Every Women Every Child initiative (World Bank, 2015), while peddling a health sector development approach that has fragmented and dismantled public health systems in LMICs (Waitzkin et al., 2007). Similarly, the BMGF positions itself as an advocate of women’s reproductive rights in a bid to expand contraceptive access for women in LMICs through Family Planning 2020, while partnering with the likes of GlaxoSmithKline, Merck, and Pfizer, ‘stakeholders’ of the Initiative and big players in the pharmaceutical industry (FP2020, 2014; Gates, 2012; BMGF, 2012, 2015). This is not to trivialize or dismiss the gains made by reproductive rights movements that have mobilized – at times with support from international donors – on various women’s reproductive health concerns over the years. A range of crucial issues, including unsafe abortion, coercive family planning and forced sterilization, have been and are being addressed by these campaigns. Indeed, women’s groups must remain vigilant in the face of ongoing mass sterilization (Burke, 2014), forced sterilization of women living with HIV (Smith, 2014), and the marketing of long-­acting reversible contraceptives to women and girls in South Asia and sub-­Saharan Africa (see UNFPA, 2014). At the same time, however, an inevitable consequence of focusing on tightly defined issues is the neglect of broader macro-­structural forces that so fundamentally shape women’s health.

TOWARD A RADICAL POST-­2015 INTERNATIONAL WOMEN’S HEALTH AGENDA The UN adopted the sustainable development agenda in September 2015. Goal 3, ‘Ensure Healthy Lives and Promote Well-­Being for All at All Ages’, outlines a list of indicators addressing various aspects of health, including achieving a reduction in the global maternal mortality ratio, universal access to sexual and reproductive health services, and universal health coverage. Broader health-­enhancing goals, such as ending poverty and malnutrition, inclusive and equitable education, universal access to water and sanitation,

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Agenda-­setting in women’s health  ­37 full employment, reducing social inequality, addressing climate change, and promoting peace and justice, have also made their way into the Sustainable Development Goals through a consultative process involving various stakeholders (Open Working Group, n.d.; Sustainable Development Knowledge Platform, 2015). Even so, reconciling the support of these lofty goals on the part of powerful states and supranational bodies with the simultaneous endorsement of a free market regime is difficult (Waitzkin, 2011). It thus remains the role of transnational women’s health movements to challenge these seemingly conflicting agendas that shape international health and development policy. Existing approaches to women’s health activism range from those adopted by feminist organizations that focus on sexual and reproductive health and rights (for example, the Women’s Global Network for Reproductive Rights, WGNRR; the International Women’s Health Coalition, IWHC; the Asia Safe Abortion Partnership) and others that address reproductive rights issues within alternative frameworks of development (for example, the Association for Women’s Rights in Development, AWID; and DAWN), to those that locate reproductive rights within broader women’s rights movements (for example, the Latin American and Caribbean Committee for the Defense of Women’s Rights, CLADEM; and Women Living Under Muslim Law). The contemporary focus of these campaigns reflects the context in which they originated. For instance, the WGNRR and IWHC are traced back to struggles for abortion rights in the 1970s and 1980s, and DAWN to the UN Decade for Women. Both DAWN and AWID address sexual and reproductive rights and political and economic dimensions of poverty and inequality, and AWID draws upon a gender justice framework for environmental sustainability (see AWID, 2015; DAWN, n.d.; IWHC, n.d.-­a; WGNRR, 2014a). Several of these organizations are credited for their contributions at UN policy-­ making fora. For instance, the IWHC critically influenced the Cairo deliberations, and the Inter-­American Convention on Sexual and Reproductive Rights has been attributed to CLADEM (IWHC, n.d.-­a; Richardson and Birn, 2011). DAWN played a crucial role at the Nairobi Women’s Conference, and provided leadership at Cairo and Beijing (DAWN, n.d.). These organizations carry on their work through branches and partners in LMICs, many receiving funds from multilateral and bilateral agencies, philanthropic foundations and women’s funds (see, for example, AWID, 2015; WGNRR, 2014b; IWHC, n.d.-­b). Their numerous interventions have valuably influenced policy-­making processes at the international level and within countries. Essential to moving forward, however, is harnessing the support of a critical mass of people by juxtaposing sexual and reproductive health and rights concerns, which are themselves of paramount importance, with broader social and health inequalities. This would entail engaging with the daily struggles of women (and men) facing poverty and social exclusion, and reframing women’s health and rights campaigns in ways that address the former concerns. An organization seeking to do so is the People’s Health Movement (PHM), a ‘global network bringing together grassroots health activists, civil society organizations, and academic institutions around the world’ (PHM, n.d.-­a). The PHM addresses gender and reproductive rights through a ‘gender health justice’ lens, and collaborates with organizations like the WGNRR and IWHC. Critically, the PHM’s understanding of health rights (inclusive of sexual and reproductive health and rights) recognizes ‘the social determinants of health and universal health entitlements/access to healthcare’, as well as (oppressive) macro-­structural forces like ‘neo-­liberal globalization, capitalism, poverty,

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38  Handbook on gender and health patriarchy, privatization of essential services, imperialism, militarization, fundamentalisms, heteronormativity, racism, casteism and ableism’ (PHM, n.d.-­b). What would a transnational women’s health movement that draws on the PHM’s framework, and remains locally grounded and representative of broader constituencies, including other movements against neoliberal reforms, look like? La Via Campesina, considered one of the strongest social movements in contemporary times, provides an instructive example. Having evolved from a long history of peasant organizing in Latin America, La Via Campesina evolved from a few autonomous rural peasant organizations led by the Coordination of Rural Organizations. In the 1990s, the Latin American campaign forged alliances with peasant organizations in Asia, Europe and North America, and later Africa, to create La Via Campesina. This global movement now consists of 164 organizations in 73 countries. Its strength is reflected in its membership of more than 200 million farmers, as well as successes gained through campaigns against neoliberal policies (La Via Campesina n.d.-­a; Martinez-­Torres and Rosset, 2010). Offering an alternative model of food sovereignty, that is, the ‘right of peoples, communities, and countries to define their own agricultural, labor, fishing, food, and land policies, which are ecologically, socially, economically and culturally appropriate to their unique circumstances’ (rather than the food security model that stresses adequate caloric consumption by whatever means), it has brought attention to agrarian reform and vital issues relating to seeds, land, water, and forests (La Via Campesina, n.d.-­b; Martinez-­Torres and Rosset, 2010). Although women’s concerns were dealt with only incidentally during its early years (Martinez-­Torres and Rosset, 2010), gender is now recognized as a crucial concern with violence against women and other forms of gender inequality addressed in contemporary campaigns (La Via Campesina, n.d.-­c). The strength of La Via Campesina is that it has been built bottom-­up and remains independent from government, funders and other external actors (Martinez-­Torres and Rosset, 2010). Imagine if such an effort could materialize in the women’s health arena, with radical activists across the globe emulating La Via Campesina’s approach to counter decades of (women’s health) co-­optation. With the new Sustainable Development Goals under way, the time is ripe to upend the reductionist approach to women’s health and embrace women’s social justice in health.

NOTES  1. These include United Nations (UN) agencies, international financial institutions, bilateral and multilateral agencies, philanthropic foundations, global public–­ private partnerships, international non-­ governmental organizations, and global health and international development consulting firms that operate in LMICs.   2. Some contemporary examples include: the UN’s Every Woman Every Child, the G-­8’s Muskoka Initiative on Maternal, Newborn and Child Health, and the Family Planning 2020 partnership, co-­sponsored by the Bill and Melinda Gates Foundation, the United Nations Population Fund, and the UK and US governments (FP2020, 2015; Government of Canada, n.d.; UN Foundation, 2015).   3. Shaped by globalization discourses, global health implies ‘a shared global susceptibility to, experience of, and responsibility for health’ that transcends national boundaries (Birn et al., 2009: 6). While ‘global health’ aims to distance itself from the asymmetrical power relations characterizing twentieth-­century ‘international health’, in practice there is little difference between the two. We use these terms somewhat interchangeably, following usage in sources and particular time periods.   4. Some forms of South–South cooperation are exceptions.

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Agenda-­setting in women’s health  ­39   5. Refers to the range of philanthropic foundations (for example, the Rockefeller Foundation and Ford Foundation, recently reinforced by the Bill and Melinda Gates Foundation), international NGOs (for example, the International Planned Parenthood Federation, Pathfinder Fund, Marie Stopes), multilateral/ bilateral and intergovernmental agencies (for example, the World Bank, USAID, UNFPA), engaged in population activities.   6. Countries aligned neither with the US-­led capitalist bloc nor the Soviet-­led communist bloc.   7. Examples include the Mothers of Plaza de Mayo in Argentina, the CoMadres in El Salvador, and the CONAVIGUA Widows in Guatemala (Di Marco, 2010; Schirmer, 1993).   8. Vertical programmes target specific diseases or health issues (for example, maternal mortality, family planning, HIV/AIDS), and are financially and logistically structured separately from other health services. They do not contribute to strengthening health systems in an overarching way, and rely on a technocratic approach that isolates specific health concerns to be addressed in the short term (Birn et al., 2009; Rosenfield and Min, 2009).   9. Achieve, by 2015, universal access to reproductive health (UN, 2008). 10. The fourth concerns ante-­natal care coverage (UN, 2008). 11. Although MDG 3 dealt with gender equality and women’s empowerment, and featured a list of indicators that sought parity between the sexes in the areas of education, literacy, employment and political representation (UN, 2008), its targets and indicators were not linked to MDG 5. 12. For Alvarez (2009: 176), ‘NGOization’ involves ‘national and global neo-­liberalism’s active promotion and official sanctioning of particular organizational forms and practices among feminist organizations and other sectors of civil society’.

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3.  Gender, health and climate change Sarah Payne

INTRODUCTION This chapter explores the impact of climate change on the health of women and men, and relationships between sex, gender and the health consequences of climate change. Climate change is already affecting mortality and morbidity, as a result of the increasing frequency of extreme weather events such as flooding and heat waves, and changes in seasons, temperatures and rainfall. Such patterns have consequences for a number of determinants of health, including, for example, food production, pricing and scarcity, water availability and quality, changing vectors of disease and the risk of accidental injury and death. These effects are however not ‘gender neutral’, but impact differently on women and men across the life course. Gender is also a significant consideration at all levels of policy-­making in strategies to mitigate climate change and to adapt to the consequences for health, yet such strategies are often gender blind. As in so many areas of policy-­making, an examination of the likely effects and the limitations of current approaches emphasizes the need for attention to gender mainstreaming across intergovernmental, regional and national levels. Across the globe there is a growing understanding of the various health impacts of climate change, and the importance of these effects, particularly for low-­income and less economically developed countries, and for poorer communities in all locations (Epstein, 2005; Costello et al., 2009). For example, while average temperatures are increasing on a global basis, these increases are particularly marked in low-­income countries in sub-­ Saharan Africa already damaged by the imposition of neoliberal economic reforms in recent decades (Navarro, 2009; Bob and Babugura, 2014). The key arguments raised here are, firstly, that climate change affects men and women in ways which primarily reflect wider gender inequalities, although sex or biological factors also play a part. The second argument is that, given such variations in impact, we need to find ways to ensure that the strategies developed to mitigate and adapt to the harms of climate change – at intergovernmental, regional and national levels – ­incorporate and address gender at all levels of decision-­making. While there is a vital and urgent need to develop global agreement on how to mitigate climate change, and to design national, regional and global forms of governance to reduce carbon emissions, monitor action and evaluate progress, the focus here is on policies to support countries and communities in adapting to, and minimizing the impact of, climate change both now and in the future. In particular, this chapter explores the impact of climate change on health and on health systems and how these problems are being addressed through adaptation strategies. Many writers have argued that gender has largely been absent from the debate over climate change and its effects (Hemmati and Röhr, 2009; Nelson et al., 2002) despite the long-­standing engagement of women’s organizations in global debate on 45 Jasmine Gideon - 9781784710859 Downloaded from Elgar Online at 11/03/2017 02:47:53AM via Sydney University

46  Handbook on gender and health the subject (Preet et al., 2010; Haysom, 2014). Arora-­Jonsson (2011) for example highlights the failure of the World Health Organization’s Atlas on Climate and Health to mention gender, despite the WHO’s formal adoption of gender mainstreaming at institutional as well as operational level (WHO, 2002). Similarly a recent paper by the WHO on mortality due to climate change makes no mention of gender variations, despite growing evidence of differences in the risks experienced by women and men (WHO, 2014). In addition, when gender is considered, it has often been from a particular and limited perspective, depicting women as both ‘vulnerable’ and ‘virtuous’ (Arora-­Jonsson, 2011: 744). The 2009 US declaration on climate change, for example, identifies women as  being at greater risk of the consequences of global warming, while suggesting that ‘gender sensitive frameworks’ need to be adopted in policies to address these effects. Similarly government policy in India classifies women as particularly likely to be adversely affected by the effects of global warming due to their domestic and productive roles and their economic vulnerability (Arora-­Jonsson, 2011). At the same time, writers have suggested that while the impact of climate change is greater for women, especially women living in countries in the Global South most affected by climate change, the causes of climate change are largely ‘man-­made’ due to men’s greater command over resources. In addition, some authors point to a distinction between the technological  and  scientific measures which have been developed to address the problem, and those focusing on cultural, behavioural and social factors which are seen as being associated with women’s needs or concerns, and which are often described as ‘soft’ (Lambrou and Piana, 2006). However, the portrayal of men as primarily responsible for environmental damage and carbon output, in contrast with women’s engagement with global efforts to counter climate change, particularly at informal levels (Hemmati and Röhr, 2009), fails to reflect a more complex reality (Skutsch, 2002; Bob and Babugura, 2014). We need to recognize that there are important differences between consumption and the beneficiaries of that consumption. Women use more energy in private homes, for example, but this is the result of gender divisions of labour which mean that women are responsible for caring work and domestic labour, and cultural expectations which mean women spend longer periods of time in the home; while men consume more energy outside the home, through the use of private transport for example. The majority of industrial production, and the contribution this makes to climate change, reflects gendered inequalities in economic power and wealth, but even so consumption of what is produced is complex, and it is difficult to attribute the benefits simplistically to either women or men. Instead, this ‘vulnerable/ virtuous’ discourse relegates women to a convenient and biologically essentialist stereotype, in which they are depicted as intrinsically closer to nature, and as carrying moral responsibility as guardians of the environment, without also holding power (Bob and Babugura, 2014). For Arora-­Jonsson (2011) such a view acts to obscure gender inequal­ ities and increase expectations placed on women, and it oversimplifies more complex positions and processes in relation to both vulnerability and responsibility, including those associated with differences within women as a group, as well as within men as a group. What these arguments highlight is the need for gender to be central in policies to address climate change (Bob and Babugura, 2014) and for a form of gender mainstreaming which recognizes complex differences between women and men, as well as gender relations of power (Payne, 2011).

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Gender, health and climate change  ­47

CLIMATE CHANGE: THE EVIDENCE The UN Framework Convention on Climate Change (IPCC) defines climate change as ‘change of climate which is attributed directly or indirectly to human activity that alters the composition of the global atmosphere’ (Intergovernmental Panel on Climate Change, 2007: 30) and notes that the evidence of such change is now unequivocal, a pos­ ition reiterated in the latest IPCC report (Intergovernmental Panel on Climate Change, 2014). Human activities, particularly in the last 50 years, have contributed to increased concentrations of greenhouse gasses in the atmosphere (Costello et al., 2009). In particular, carbon dioxide (CO2) emissions due to the burning of fossil fuels combined with deforestation and alterations in land use have contributed to an increase in global average temperature, differences in weather patterns and increasing sea-­levels (Lambrou and Piana, 2006). The consequences for human life and activities have already started, and will continue to have far-­reaching effects across the world. In many countries these changes are accompanied and exacerbated by unsustainable development, rapid and unplanned urbanization and increased levels of water contamination from industry and housing (WHO and WMO, 2012).

THE HEALTH EFFECTS OF CLIMATE CHANGE Climate change has been identified as a barrier to the achievement of the Millennium Development Goals due to the impact on economic growth and poverty (Lambrou and Piana, 2006), and it is now seen as critical in the creation of the post-­2015 Sustainable Development Goals (OWG, 2014). A major part of this concern lies with the evidence of the impact of climate change on health (Lambrou and Piana, 2006; Intergovernmental Panel on Climate Change, 2014). The impact of climate change on health and the global burden of disease is wide-­ ranging. It includes greater risks of premature mortality and higher morbidity, through increasing rates of a number of communicable and non-­communicable diseases and greater risks of injury (WHO, 2014). Costello et al. (2009) for example note that even conservative predictions of the impact of climate change on health suggest it will contribute 5.5 million disability-­adjusted life years (DALYs) to the global burden of disease per annum, while the WHO estimates that mortality will increase by 250 000 deaths per annum (WHO, 2014). The list of communicable diseases which are likely to increase as a result of climate change includes malaria, dengue fever, leptospirosis, leishmaniasis, tick-­borne encephalitis, meningitis and cholera (Epstein, 2005). Rates of some non-­communicable diseases are also increasing as a consequence of climate change, including cardiovascular disease, asthma and respiratory disease, mental ill-­health, ultra-­violet (UV) radiation and malnutrition (Kim et al., 2014). Other threats to health include the growing numbers of accidental deaths and injury resulting from severe weather events, as well as increases in stress-­related violence, including gender-­based violence and self-­harm (Barnett and Adger, 2007). There are two main mechanisms shaping these changing risk factors. The first is the increase in the burden of disease directly associated with severe weather events and the

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48  Handbook on gender and health short-­term and long-­term consequences of these. The second mechanism is the impact of climate change on disease vectors and broader determinants of health such as agricultural yield, poverty, migration, urbanization, overcrowding, lack of adequate sanitation and access to clean water, changing patterns of employment and employment-­related risks (Costello et al., 2009). The sections below discuss these different patterns in more detail, highlighting the ways in which the impact of various climate change-­related influences on health differs for women and men. Severe Weather Events Climate change is associated with an increase in a range of severe weather events and associated emergencies, including flooding, tropical storms, cyclones and heat waves, which present health risks for both men and women. In 2011, for example, 332 weather-­ related disasters in more than 100 countries impacted on 244 million people and led to more than 30 000 deaths worldwide (WHO and WMO, 2012). While such events are increasing in frequency in both high-­and low-­income countries, the impact is greatest among the poorest countries, and among the poorest populations everywhere (Bob and Babugura, 2014). Flooding presents a major threat to both mortality and morbidity due to drowning and accidents, and the damage to infrastructure, food and water supplies, and sanitation (Lambrou and Piana, 2006; Bob and Babugura, 2014). There is an increased risk of both communicable diseases such as cholera, and non-­communicable diseases, following long-­ term impacts such as the destruction of homes and possessions, displacement, land and crop damage, and loss of livelihoods (Khosla and Masaud, 2010). Similar increases in mortality and morbidity reflect the growing frequency and severity of tropical cyclones and storms, which lead to accidental injury, and other health effects due to displacement, damage caused to crops, land, shelter, water, electricity and health systems, and poverty (Khosla and Masaud, 2010). These severe weather events can affect women and men differently however. In many countries in Latin America and Asia women are less likely to be able to swim, and are reluctant to leave homes without being accompanied by a male family member, which increases their risk of drowning and injury in severe weather events such as flooding and tropical cyclones (Nelson et al., 2002; WHO, 2012). Gendered expectations also play a part in the threat to men’s health and survival, particularly discourses of masculinity which endorse male risk-­taking behaviour and attempts to protect their families and possessions (Arora-­Jonsson, 2011). In Hurricane Mitch in 1998, for example, more men died in the immediate event and aftermath, reflecting their greater likelihood of being outside at the time, including their participation in rescue work (Nelson et al., 2002; Correia, 2001). Severe heat and ‘heat stress’ are also becoming more common, and heat waves are lasting longer (Costello et al., 2009; Epstein, 2005). Again this occurs in both wealthier regions – the heatwave in Europe in the summer of 2003 for example – and in poorer parts of the world (Epstein, 2005). As a result of changes in the climate it is estimated that excessive heat will be more frequent and more intense, with predictions of severe heat events every 2–5 years by 2050, in comparison with current risks of heat waves every 20 years or so (WHO and WMO, 2012). As a result, heat-­related deaths globally will increase by more than 250 per cent by 2050 (Hajat et al., 2014).

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Gender, health and climate change  ­49 The consequences of heat stress are exacerbated by the shift towards urbanization and the growth in populations living in cities, due to the urban ‘heat-­island’ effect which further raises temperatures (Hajat et al., 2014). The health effects of heat stress are greater in overcrowded cities with weak infrastructure, poor sanitation and lack of clean water (Khosla and Masaud, 2010). Heat stress is particularly significant for older people, people with a pre-­existing health condition, those working in overcrowded workplaces without cooling systems, and agricultural workers (Kovats and Hajat, 2008). The health burden associated with raised temperatures includes increased levels of cardiovascular disease, heat stroke and respiratory disease, especially asthma, due to the quality of air and increasing air pollution and higher dust volumes, together with increased prevalence of allergies as a result of prolonged pollen seasons (Epstein, 2005; Kim et al., 2014; McMichael et al., 2006). Food poisoning is also becoming more common, a consequence of higher temperatures which promote the growth of bacteria (McMichael et al., 2006). There are further risks for mental health, including self-­harm and violence, due to increased stress, reduced social interaction and greater isolation (McMichael et al., 2006; Hanna et al., 2011; Kim et al., 2014). Again there are gender differences. Studies suggest that women are more likely to die than men during a heat wave, although risks vary across the life course. In the 2003 heat wave in Europe, for example, more women died overall, particularly older women (Goh, 2012) but among younger age groups more men died due to the risks posed by heat exposure in paid employment (McMichael et al., 2006; Hanna et al., 2011; Hajat et al., 2014). Older women are more likely than older men to live alone, which increases their vulnerability if they experience respiratory problems or cardiac arrest (Demetriades and Esplen, 2008), while high temperatures also increase the risk of some pregnancy-­related conditions such as eclampsia (Goh, 2012). UV radiation is also becoming more severe, and is associated with a growing prevalence of skin cancer and damage to eyes, while emerging evidence suggests that increasing levels of UV radiation encourage the spread of infectious disease (WHO and WMO, 2012; Kim et al., 2014). Differences between women and men in these risks are complex, reflecting regional, cultural and socio-­economic variations as well as those associated with gender. Rates of skin cancer for example are increasing particularly quickly in high-­ income countries among white populations (Nikolaou and Stratigos, 2014), but there are geographical differences in the relative risks of women or men, with higher male melanoma prevalence in the US, Australia, New Zealand and Southern Europe, while rates are higher for women in Western and Northern Europe (Nikolaou and Stratigos, 2014). Outdoor workers are particularly at risk, and while this includes both men and women, gendered divisions of labour in agriculture and construction often lead to increased risks for men (Carey et al., 2014). Men are also less likely to use sunscreen, and have lower levels of knowledge about the risk of UV radiation (Falk and Anderson, 2013; Haluza et al., 2014). Changes in Vector-­Borne Diseases A key health impact of climate change is the change in transmission cycles and occurrence of vector-­borne diseases which involve biting insects (Kim et al., 2014). For example there is a higher risk of communicable diseases such as malaria and dengue fever due to

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50  Handbook on gender and health the extension of the mosquito breeding season and a reduction in the maturation period, leading to increased numbers of mosquitoes, while temperature changes also result in mosquitoes feeding more frequently, again adding to the risk they present (Epstein, 2005; Aguilar, 2010). Mosquitoes are also now being found in regions previously clear of them, exposing new populations, with less inbuilt resistance, to diseases like malaria and dengue fever. In Sweden diseases carried by ticks have become more common in northern regions as warmer winters lead to northward migration by insects. Other diseases such as meningitis also spread more easily, and changes to the climate increase the risk of epidemics in areas where the disease is common, particularly sub-­Saharan Africa, due to decreasing humidity (Hajat et al., 2014; WHO and WMO, 2012). As with other effects, the impact of climate change on disease vectors is linked to the rapid growth of cities. For example, diseases spread by rodents have become more common due to urbanization as well as temperature change and a decrease in predators which control rodent populations (Epstein, 2005). Dengue fever is also increasing in many cities, particularly those in tropical and subtropical areas, due to overcrowding, the increase in standing water which encourages mosquitoes, and higher temperatures which impact on the development of the virus and lead to higher rates of rates of transmission (WHO and WMO, 2012). There are again differences between women and men in the impact of these shifts, which reflect both biological and gender-­linked influences on health (Aguilar, 2010). For example, women are more susceptible to malaria during pregnancy, as a result of hormonal changes which attract mosquitoes and increase the risk of being bitten, while pregnant women are also more likely to need to leave protective shelter in order to urinate during the night, when mosquitoes are most active. These factors place pregnant women at greater risk compared with other women and with men (WHO, 2011). Gendered social determinants also play a part. Women are also usually responsible for the collection of water, for example, which means that they spend more time in close proximity to mosquitoes (Parikh, 2012). However, opportunistic distribution of insecticide-­treated bed nets at antenatal care has increased the numbers of women who are protected at night, and even in universal distribution programmes gender differences remain, with more women reporting net use (Garley et al., 2013). There are particular gaps in the number of young men using nets, reflecting discourses of masculinity which minimize danger and encourage risk-­taking behaviour, including not using protective nets. Water and Food Climate change has already begun to affect ecosystems, in a range of ways (Costello et al., 2009), including impacts on water supply and quality, and the use and availability of water in agriculture and food production (WHO and WMO, 2012). Water scarcity over both the long and short term has a range of important consequences for health. Climate change has increased the frequency and severity of drought, due to the impact on the hydrological cycle (Epstein, 2005). As a result of such changes, annual rainfall is increasingly concentrated in shorter time frames, and in rainy seasons rainfall is less able to drain away, leading to soil erosion and a decline in the productivity of land (Epstein, 2005). In addition, inadequate water storage, for use in periods without rain,

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Gender, health and climate change  ­51 decreases yield and increases the likelihood of crop failure. Rising sea levels and flooding from the sea reduce the amount of agricultural land available while salination of land also adds to the threat to health. Saline-­contaminated drinking water, for example, increases the risk of pre-­ eclampsia, eclampsia and hypertension among pregnant women (WHO, 2012). Water quality is also deteriorating due to the growth in cities and populations with no access to sanitation, the improper and inadequate treatment of waste water, and pollution from industrial and agricultural run-­off (Khosla and Masaud, 2010). While water supply and quality are adversely affected by climate change, the demand for water is also increasing, as a result of increasing use of water in both industry and agriculture. There are many threats to health as a result of these changes. One risk increasingly experienced by both more-­and less-­developed countries is that of accidents and respiratory health problems due to fires, which become more frequent and spread more quickly in drought conditions (D’Amato et al., 2014), and which are harder to tackle in the absence of adequate water supplies. In addition to the rise in dengue fever and malaria, as discussed earlier, health is threatened by the lack of sufficient clean drinking water in dry seasons. Both diarrhoea and cholera are also more common as a result of reductions in water supply, increases in water temperature and water contamination (WHO and WMO, 2012; Kim et al., 2014). Again there are some gender differences in the impact of changes to water supply. Women are typically responsible for water collection, and lack of water means that they need to travel further afield, while domestic labour and caring work are made more difficult without adequate water supplies (Goh, 2012; Meyiwa et al., 2014). They are also more exposed to water-­borne disease because of these gender divisions in labour. Climate change also impacts on the availability and price of food. Water stress and reduced water quality, land loss and salination due to flooding and rising sea levels are all factors in reduced agricultural yield, while temperature changes and shifts in seasonal patterns, the loss of topsoil and loss of eco-­diversity are also important (Costello et al., 2009). Although the impact of climate change on agricultural yield varies, with some crops in some regions becoming more productive (Lambrou and Piana, 2006), this is likely to be offset by reductions elsewhere (Nelson et al., 2002; Costello et al., 2009). One of the main health effects of reduced yields is greater food insecurity, hunger and malnutrition, due to inadequate levels of food and food of poor nutritional quality (Costello et al., 2009). It is estimated that 2.5 million more children around the world will go hungry as a consequence of climate change, and that 20 per cent of the global population will be affected by 2050; mainly those living in sub-­Saharan Africa (WHO and WMO, 2012). Malnutrition has a number of health consequences including increased vulnerability to both communicable and non-­communicable disease, low birth weight and impaired intellectual development. Again there are gender differences in how these risks are experienced. Women’s reproductive health is adversely affected by malnutrition, increasing risks of complications in pregnancy and labour and greater difficulties in breastfeeding (WHO and WMO, 2012). There are also gender differences in access to food in many cultures, which means that women consume less of household food, and in times of shortage this presents particular risks for them (Goh, 2012).

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52  Handbook on gender and health Women are responsible for more than half of global food production and the loss of agricultural yield particularly affects women’s incomes and livelihood, and in turn impacts on their opportunities for health (Aguilar, 2010). However, there are health risks for men too, for example changing patterns in yield and prices are associated with marked increases in suicide among male farmers in a number of countries, reflecting men’s positions as breadwinner and head of household and the impact of such economic stresses on their mental health (Kim et al., 2014; Patel, 2007). Migration, Conflict and Violence Climate change is often described as posing various kinds of security threat. One of the earliest debates over the impact of climate change referred to an increased risk of violent conflict, for example the risk of ‘water wars’ in response to increasing water scarcity and poor-­quality water (Barnett, 2003; Barnett and Adger, 2007). However, the impact is likely to vary between settings and contexts, reflecting the extent of  change  and threat to livelihoods or health for example (Nordås and Gleditsch, 2013). In part, perceptions of security threat reflect the tensions arising from increasing levels of migration, often due to fears held by indigenous populations, and the increased stress on limited resources such as water, space, food and employment (Reuveny, 2007). Climate change increases frequency of migration, as people move away from the worst-­affected areas and in search of more secure income, employment, shelter, water, food and other necessities. The negative consequences of changes to rainfall and seasons for example, and declining agricultural yield, force people to seek alternatives, usually through inward urban migration (Reuveny, 2007). In addition, climate change reduces the ability of the state to support people in terms of income protection and welfare services, particularly in low-­income countries (Barnett and Adger, 2007), with migrants least well provided for by health services. Displacement and migration and their impact on health are also gendered (Nelson et al., 2002). When men migrate to find an alternative source of income and paid employment, women are often left behind (Parikh, 2012; Aguilar, 2010). This can impact on women’s health in a range of ways: household income can increase when men send remittances back home, but women left behind have an increased workload and ­responsibilities, and can be exposed to other risks; for example if migrant partners engage in unprotected sex during their time away from home, this leads to further health  threats for their wives and partners on their return (Goh, 2012). Women may also be expected to follow men, leaving behind family systems of support and ­ opportunities for independent income, and increasing their reliance on men (Goh, 2012). A further risk is that of gender-­based physical, emotional and sexual violence following migration. For example, when people seek refuge in temporary shelters and emergency housing following severe weather events there are particular dangers for women and girls who are exposed to the risk of assault and harassment in such camps (Demetriades and Esplen, 2008; Jaggernath, 2014). Household and domestic violence towards women also increases following severe weather events due to heightened tension and stress and the impact of displacement and loss on male identity (WHO, 2012).

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Gender, health and climate change  ­53

EXPLAINING GENDER DIFFERENCES IN THE EFFECTS OF CLIMATE CHANGE ON HEALTH These differences between women and men in their vulnerability to the burden of climate ­change and its impact on health reflect underlying gender inequality and gender inequity (Bob and Babugura, 2014). Gender equality is described by the WHO as ‘the absence of discrimination on the basis of a person’s sex in opportunities, allocation of resources or benefits, and access to services’ (WHO, 2002: 3), while gender equity reflects issues of social justice: ‘gender equity means fairness and justice in the distribution of benefits, power, resources and responsibilities between women and men’ (WHO, 2002: 3). This places the emphasis on differences between women and men in terms of access to various social determinants of health, and expectations placed on them, and highlights the need to explore and address underlying gender relations of power in both mitigation and adaptation strategies. Some of the health risks are associated with biological influences including hormonal, genetic and reproductive differences between women and men. Women’s reproductive health in particular is threatened by many of the impacts of climate change, including for example the impact of nutritional deficiency or the effects of unsafe drinking water on maternal health. However, most of the differences in the burden of risk reflect gender variations, including structural differences between women and men, command over resources, gendered divisions of roles and responsibilities, and gender discourse and behaviour. One of the leading factors shaping the impact of climate change on health is poverty (Costello et al., 2009). For example, climate change increases costs of staple foods, and the impact of this is more severe for low-­income households. Poorer households are also less able to afford to protection from adverse effects – air conditioning, for example, in severe heat – while loss of income due to severe weather events, and destruction to land, crops or tools, are also important (Hajat et al., 2014). At the same time, climate change increases the risk of poverty for many. There are gendered differences in these threats, although these vary between countries and regions. Women are often more exposed to poverty, particularly in less economically developed regions, and have less capacity in relation to adaptation and mitigation strategies (Aguilar, 2010; Nelson et al., 2002; Lambrou and Piana, 2006). Women farmers for example are often engaged in small-­scale, low-­technology, subsistence farming and have less secure forms of tenure than men (Hemmati and Röhr, 2009; Aguilar, 2010). As a result, they are more vulnerable to financial shocks, which affects their ability to withstand short-­term losses (Aguilar, 2010), and both short-­term weather events and longer term impacts of climate change have a greater impact on their livelihood and opportunities for health in comparison with men. Women in cities are also more likely than men to be living in poor-­quality housing, in slums, and in areas with high levels of environmental risk (WHO, 2012). However, differences within women as a group, or men, are also important. Arora-­ Jonsson (2011) for example describes how low-­income lower-­caste women in India experienced less risk from flooding because of government housing grants which meant that their housing was more able to resist flood damage in comparison with other low-­income groups.

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54  Handbook on gender and health Access to health care is also important in gendered experiences of climate change. While increases in infectious diseases affect both women and men, women are often less able to use health services or consult health professionals when infected, because they cannot access household finances to pay for treatment or for travel, they are less likely to be in the forms of paid work which include health insurance, they cannot afford the time to seek health care because of work or caring responsibilities, and because of cultural prohibitions on women travelling alone (Demetriades and Esplen, 2008; WHO, 2011). Gender divisions in labour also pay a part (Nelson et al., 2002). This includes variations between women and men in ‘poverty of time’ which reflect differences in the roles and expectations of women and men (Demetriades and Esplen, 2008). Climate change impacts on women’s labour, time and stress due to increased scarcity of water, firewood and food, because these are often women’s responsibility (Lambrou and Piana, 2006; WHO, 2011). It also means women are often exposed to heat-­stress for longer periods, while carrying out this work (Arora-­Jonsson, 2011). Women’s labour as informal carers within the household also increases as a result of the growing burden of disease and the work of caring for others (Nelson et al., 2002; WHO, 2011). Men, on the other hand, may experience an increased risk when traditional male roles expose them to other threats, such as the rise in accidents among men engaged in Arctic hunting as a result of the dangers of thinning ice, or the risk of blindness from river fishing due to increased spread of the flies that cause this disease (WHO, 2012). Thirdly, gender discourses which impact on behaviours and expectations of women and men are important. Cultural expectations in relation to food consumption, for example, including the idea that ‘women eat least and last’, mean that food insecurity and shortages affect women disproportionately (Nelson et al., 2002). Other gendered discourses impact differently on women and men. While each may experience a heightened risk of accident and death in severe weather events, this is for different reasons, while the experience and effects of increased levels of stress, tension and violence also vary between women and men. These various forms of gender-­linked influence share a common root: gender relations of power. A number of writers have highlighted the need to avoid oversimplification when exploring gender differences in the impact of climate change, particularly the need to avoid the tendency to represent ‘women everywhere as a homogenous, subjugated group – “the poorest of the poor”’ (Demetriades and Esplen, 2008: 24). Instead we need to consider intersecting forms of disadvantage and inequality, and how these connect with power, exposure to risk, and with opportunities to adapt or to change. This includes a much more explicit recognition of the vulnerability of men and boys in policy debate and a better appreciation of how the impact of climate change for everyone is mediated through both gender and other forms of social injustice (Demetriades and Epstein, 2008).

GENDERING STRATEGIES TO ADDRESS CLIMATE CHANGE So how should intergovernmental, regional and national policies develop adaption strategies which address the health needs of both women and men (Bob and Babugura, 2014)? The international response to climate change includes the UN Framework Convention

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Gender, health and climate change  ­55 on Climate Change adopted in 1992 and the Kyoto Protocol, which encompassed ­commitments by more economically developed countries to reduce carbon emissions, while all parties to the Conventions share a commitment to introduce strategies to adapt to the impact of climate change and mitigate the effects (Lambrou and Piana, 2006). Actions by the WHO include the development of a workplan to support low-­and middle-­ income countries in developing adaptation strategies and protecting human health, together with advocacy and awareness-­raising (WHO, 2008). Such policies need to address the main requirements for health – clean water, shelter, sanitation, clean air and food security – together with access to timely and appropriate health care. Adaptation strategies include a focus on the support and protection of livelihoods, through the development of sustainable economic opportunities for the poorest groups, capacity development in relation to agriculture, including crop diversity for example, and better early warning systems and management of risk such as better coastal defences (Lambrou and Piana, 2006). For example, in India men are twice as likely as women to receive weather alerts which enable better decisions about harvesting as well as being able to protect crops or other assets (WHO, 2012). Protection of income and capacity-­building have gendered implications and should be approached from a viewpoint in which gender issues are central. The protection of livelihood in the face of climate change for example needs to recognize differences between women and men in sources and fragility of income, kinds of work, both paid and unpaid, and access to resources within households and local communities, including opportunities and constraints such as domestic labour or caring responsibilities, education and culture. Capacity development and agricultural adaptation strategies also need to identify gender differences in decision-­making power (Lambrou and Piana, 2006). Similarly, other adaptation policies must be developed along gender-­sensitive lines. This includes, for example, practical steps: safe shelters which are accessible for women, without physical or cultural barriers, and strategies to support the work of cleaning up after severe events and caring for household members who are ill (WHO, 2011). There is also a need for programmes to address gendered behaviours which affect both women and men, including gender-­based violence (WHO, 2011). At present household-­and community-­level strategies to mitigate climate change often address women and men separately, and women are expected to take a lead in responsibility for environmental protection (Nelson et al., 2002). In some parts of the world women have organized locally to develop sustainable changes, such as crop diversification (Aguilar, 2010). Addressing women directly is often seen as a way to increase the efficiency of programmes (Skutsch, 2002), and reflects a common use of the business case to justify gender mainstreaming (Nhamo, 2014). But we need to be wary of seeing women simplistically as the solution. While the majority of intergovernmental and non-­governmental agencies involved in these strategies have formally adopted gender mainstreaming, and highlight women’s roles and the need for gender-­sensitive approaches to sustainable development, policy development and implementation has revealed a narrow view of what this means in practice (Denton, 2002; Preet et al., 2010). Attention to gender in climate change policies has increased in the past decade, but the integration of gender concerns in conferences such as the Conference of the Parties (COP) 18 and 19 remains limited (Olson, 2014), and women’s needs and their voices are still often marginalized at community and local level

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56  Handbook on gender and health (Bob and Babugura, 2014; Siulemba and Moodley, 2014). And the inclusion of more women at all levels of policy-­making does not automatically lead to increased attention being paid to gender, as Magnusdottir and Kronsell (2015) point out in their analysis of the ways in which the inclusion of more women in climate change policy debate in Sweden did not lead to more acknowledgment of gender issues. There is also a need to address the knowledge gap through more research and knowledge transfer across different organizations and networks, and evaluation of strategies that have been developed (WHO, 2012). As with other questions of gender and health, the health impact of climate change needs gender-­disaggregated data (Lambrou and Piana, 2006; Mayhew et al., 2014). However, while there is an increasing understanding of gendered aspects of climate change impacts, this has tended to concentrate on more obvious or measurable elements, and knowledge is weaker on indirect costs such as the impact on transport, infrastructure, housing or informal employment (Otzelberger, 2011). An evidence-­based approach would also help to address simplistic and stereotypical notions of both women and men, and to ensure gender considerations are built into all decisions (Bob and Babugura, 2014). While in many cases gender inequity impacts most on women, leaving them particularly affected by climate change, we also need to address the slippage at policy level which means that ‘gender’ is translated in practice to mean ‘women’. As a result, gender relations of power and the distribution of social and economic justice remain unexplored, and continue to act as a barrier to change. Gender differences in how women and men are involved in adaptation at all scales of policy-­making perpetuate existing differences in economic and political power. Policies and programmes need to consider underlying gender inequality and inequity, not simply address women in their capacity as carers or farmers (Otzelberger, 2011; WHO, 2011). Donors also play an important role in supporting countries and communities in coping and adaptation, and can play a lead role in embedding gender considerations in policy development (Otzelberger, 2011). Donors are often more engaged in social projects at a local level, which places them in a good position to develop capacity. While there is evidence that many such donors are aware of gender, there are also a number of barriers, including technical and resource problems, lack of understanding, weak communication and ‘mainstreaming fatigue’ (Otzelberger, 2011). Finally, gender differences in how health systems in general respond to the needs of women and men are exacerbated by the impact of climate change on such systems, especially in poorer countries. Low-­income countries will experience the greatest increases in both communicable and non-­communicable diseases, and weak health systems facing ongoing problems associated with health worker migration, poor infrastructure, lack of preparedness for emergencies and lack of finance, for example, increase the severity of the problems they are likely to face when they seek to develop adaptation strategies (Mayhew et al., 2014).

CONCLUSION Gender equality is a prerequisite for both sustainable development and for strategies to address the health impacts of climate change. Gender mainstreaming is essential

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Gender, health and climate change  ­57 (Otzelberger, 2011), but hierarchies of power remain, gender is still not fully represented and the concept continues to be interpreted in a narrow way (Olson, 2014). Although some progress has been made in incorporating a gender perspective at intergovernmental and national levels, this perspective is too often framed in a way which prevents the identification of gender relations of power and the relationship between gender equity, power and outcomes. While much of the climate change discourse focuses either on women’s vulnerability, or on efficiency and a business case for mainstreaming gender in approaches to climate change mitigation and adaptation, the argument should be based on social justice and should be rights-­based, in ways which encompass both the costs of climate change for women and men, and an appreciation of the significance of gender relations in how we go about this.

REFERENCES Aguilar, L. (2010), Establishing the linkages between gender and climate change adaptation and mitigation. In: Dankelman, I. (ed.) Gender and Climate Change: An Introduction. London: Earthscan. Arora-­Jonsson, S. (2011), Virtue and vulnerability: discourses on women, gender and climate change. Global Environmental Change 21: 744–751. Barnett, J. (2003), Security and climate change. Global Environmental Change 13: 7–17. Barnett, J. and Adger, W.N. (2007), Climate change, human security and violent conflict. Political Geography 26: 639–655. Bob, U. and Babugura, A. (2014), Contextualising and conceptualising gender and climate change in Africa. Agenda: Empowering Women for Gender Equity 28: 3–15. Carey, R.N., Glass, D.C., Peters, S., et al. (2014), Occupational exposure to solar radiation in Australia: who is exposed and what protection do they use?. Australian and New Zealand Journal of Public Health 38: 54–59. Correia, M. (2001), Hurricane Mitch – the gender effects of coping and crises. Prem Notes, Washington, DC: World Bank. Costello, A., Abbas, M., Allen, A., et al. (2009), Managing the health effects of climate change. Lancet 373: 1693–1733. D’Amato, G., Cecchi, L., D’Amato, M., et al. (2014), Climate change and respiratory diseases. European Respiratory Review 23: 161–169. Demetriades, J. and Esplen, E. (2008), The gender dimensions of poverty and climate change adaptation. IDS Bulletin 39: 24–31. Denton, F. (2002), Climate change vulnerability, impacts, and adaptation: why does gender matter?. Gender and Development 10: 10–20. Epstein, P.R. (2005), Climate change and human health. New England Journal of Medicine 353: 1433–1436. Falk, M. and Anderson, C.D. (2013), Influence of age, gender, educational level and self-­estimation of skin type on sun exposure habits and readiness to increase sun protection. Cancer Epidemiology 37: 127–132. Garley, A.E., Ivanovich, E., Eckert, E., et al. (2013), Gender differences in the use of insecticide-­treated nets after a universal free distribution campaign in Kano State, Nigeria: post-­campaign survey results. Malaria Journal 12: 119. Goh, A.H. (2012), A literature review of the gender-­differentiated impacts of climate change on women’s and men’s assets and well-­being in developing countries. Washington, DC: International Food Policy Research Institute (IFPRI). Hajat, S., Vardoulakis, S., Heaviside, C., et al. (2014), Climate change effects on human health: projections of temperature-­related mortality for the UK during the 2020s, 2050s and 2080s. Journal of Epidemiology and Community Health 68: 641–648. Haluza, D., Moshammer, H., Kundi, M., et al. (2014), Public (skin) health perspectives of gender differences in tanning habits and sun protective behaviour: a cross-­sectional questionnaire survey. Wiener klinische Wochenschrift 127: 1–8. Hanna, E.G., Kjellstrom, T., Bennett, C., et al. (2011), Climate change and rising heat: population health ­implications for working people in Australia. Asia-­Pacific Journal of Public Health 23: 14S–26S. Haysom, L. (2014), The Environment and Gender Index: ranking gender accountability by governments in climate change policies. Agenda: Empowering Women for Gender Equity 28: 179–183.

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58  Handbook on gender and health Hemmati, M. and Röhr, U. (2009), Engendering the climate-­change negotiations: experiences, challenges, and steps forward. Gender and Development 17: 19–32. Intergovernmental Panel on Climate Change (2007), Fourth Assessment Report: Contribution of Working Groups I, II and III to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Geneva: Intergovernmental Panel on Climate Change. Intergovernmental Panel on Climate Change (2014), Climate change 2014: Synthesis report (IPCC Fifth Assessment Synthesis Report). Geneva: Intergovernmental Panel on Climate Change. Jaggernath, J. (2014), Women, climate change and environmentally-­ induced conflicts in Africa. Agenda: Empowering Women for Gender Equity 28: 90–101. Khosla, P. and Masaud, A. (2010), Cities, climate change and gender: a brief overview. In: Dankelman, I. (ed.) Gender and Climate Change: An Introduction. London: Earthscan. Kim, K-­H., Kabir, E. and Ara Jahan, S. (2014), A review of the consequences of global climate change on human health. Journal of Environmental Science and Health, Part C 32: 299–318. Kovats, R.S. and Hajat, S. (2008), Heat stress and public health: a critical review. Annual Review of Public Health 29: 41–55. Lambrou, Y. and Piana, G. (2006), Gender: the missing component of the response to climate change. Rome: Food and Agriculture Organization of the United Nations (FAO). Magnusdottir, G.L. and Kronsell, A. (2015), The (in)visibility of gender in Scandinavian climate policy-­ making. International Feminist Journal of Politics 17(2): 308–326. Mayhew, S., Van Belle, S. and Hammer, M. (2014), Are we ready to build health systems that consider the climate? Journal of Health Services Research and Policy 19: 124–127. McMichael, A.J., Woodruff, R.E. and Hales, S. (2006), Climate change and human health: present and future risks. Lancet 367: 859–869. Meyiwa, T., Maseti, T., Ngubane, S., et al. (2014), Women in selected rural municipalities: resilience and agency against vulnerabilities to climate change. Agenda: Empowering Women for gender Equity 28: 102–114. Navarro, V. (2009), What we mean by social determinants of health. International Journal of Health Services 39: 4230441. Nelson, V., Meadows, K., Cannon, T., et al. (2002), Uncertain predictions, invisible impacts, and the need to mainstream gender in climate change adaptations. Gender and Development 10: 51–59. Nhamo, G. (2014), Addressing women in climate change policies: a focus on selected east and southern African countries. Agenda: Empowering Women for Gender Equity 28: 156–167. Nikolaou, V. and Stratigos, A. (2014), Emerging trends in the epidemiology of melanoma. British Journal of Dermatology 170: 11–19. Nordås, R. and Gleditsch, N.P. (2013), The IPCC, human security, and the climate–conflict nexus. In: Redclifft, M.R. and Grasso, M. (eds) Handbook on Climate Change and Human Security. Cheltenham, UK and Northampton, MA, USA: Edward Elgar. Olson, J. (2014), Whose voices matter? Gender inequality in the United Nations Framework Convention on Climate Change. Agenda: Empowering Women for Gender Equity 28: 184–187. Otzelberger, A. (2011), Gender-­responsive strategies on climate change: recent progress and ways forward for donors. Brighton: Institute for Development Studies. OWG (2014), Sustainable Development Goals: full report of the Open Working Group of the UN General Assembly on Sustainable Development Goals A/68/970. United Nations. Parikh, J. (2012), Gender and climate change framework for analysis, policy & action. UNDP (India). Patel, R. (2007), Stuffed and starved: Markets, Power and the Hidden Battle for the World Food System, London: Portobello Books. Payne, S. (2011), Beijing fifteen years on: the persistence of barriers to gender mainstreaming in health policy. Social Politics 18: 515–542. Preet, R., Nilsson, M., Schumann, B., et al. (2010), The gender perspective in climate change and global health. Global Health Action 2010(3): 10.3402/gha.v3i0.5720. doi:10.3402/gha.v3i0.5720. Reuveny, R. (2007), Climate change-­induced migration and violent conflict. Political Geography 26: 656–673. Siulemba, K. and Moodley, V. (2014), A gendered analysis of sustainable agricultural practices with changing climate in the Chankumba agricultural community, Zambia. Agenda: Empowering Women for Gender Equity 28: 135–146. Skutsch, M.M. (2002), Protocols, treaties, and action: the ‘climate change process’ viewed through gender spectacles. Gender and Development 10: 30–39. WHO (2002), Mainstreaming gender equity in health: the need to move forward. The Madrid Statement. Geneva: World Health Organization. WHO (2008), Climate change and health. Geneva: World Health Organization. WHO (2011), Gender, climate change and health. http://www.who.int/globalchange/GenderClimateChange Healthfinal (accessed October 2014).

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Gender, health and climate change  ­59 WHO (2012), Mainstreaming gender in health adaptation to climate change programmes. Geneva: World Health Organization. WHO (2014), Quantitative risk assessment of the effects of climate change on selected causes of death, 2030s and 2050s. Geneva. WHO and WMO (2012), Atlas of Health and Climate Change. Geneva: World Health Organization, World Meterological Organisation.

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4.  Towards a new political agenda for indigenous women’s health in Latin America in the post-­2015 era Anna Coates and Sandra Del Pino*

INTRODUCTION As we move further into the twenty-­first century and towards a new era for the development agenda, the global political agenda is beginning to recognize the unequal status of indigenous peoples with respect to the right to health. In particular, there is an increasingly strong emerging consciousness of the ways in which gender inequalities, and marginalization and discrimination on the basis of ethnic identity (including institutional discrimination), interact to create a yet more negative outlook for indigenous women in terms of their health status, the social determinants of health and access to quality health care. With varying degrees of attention, this has been a constant within the public health and development discourse over many years, in particular in Latin America where proportions of indigenous populations are high and ethnic inequalities are stark. However, data pinpointing the precise detail of such realities are as yet in their infancy. This lack of data has had a profound and cyclical effect since, without the crucial evidence to make the political argument for a focus on indigenous peoples, entry onto the normative agenda has been an uphill struggle. Conversely, without a clear normative framework mandating governments to ensure a specific focus on cultural diversity in health in particular, investments are not made into data generation nor into policy (often formulated in response to the evidence provided by data). The post-­ 2015 development agenda, or so-­ called Sustainable Development Goals (SDGs), therefore represents a crucial opportunity for advancing the normative framework and commitments for indigenous women’s health in Latin America. This chapter seeks to first present some of the key reliant comparative data that are available, illustrating the profundity of the health inequalities faced by indigenous women in Latin America. Subsequently, an overview and brief analysis of the current normative frameworks at global and regional levels that make reference to, or which can be applied, to indigenous women’s health are provided. Reference is briefly made to the ways these normative frameworks have recently been operationalized in selected national legal frameworks in the region that specifically promote and/or make mention of indigenous women’s health. The SDGs should ideally seek to fill the gaps in these existing frameworks in terms of addressing the most crucial health concerns for indigenous women in order that governments can identify how these issues play out in their own national contexts and formulate adequate policy responses. However, this chapter points to some of the complexities of including indigenous women’s health issues in the new framework in a meaningful way. 60 Jasmine Gideon - 9781784710859 Downloaded from Elgar Online at 11/03/2017 02:47:53AM via Sydney University

Towards a new political agenda for indigenous women’s health  ­61 In particular, the difficulties are noted of formulating a framework that adequately deals with the potentially conflicting nature of community, cultural and individual human and, particularly, women’s rights in relation to health and that has real potential to be implemented in improved national legal frameworks in the region. Finally, the chapter discusses how health goals for indigenous women may articulate with more generalized goals related to health, gender equality and women’s empowerment within this sustainable development framework.

INDIGENOUS WOMEN’S HEALTH IN LATIN AMERICA Reproductive, Sexual and Maternal Health The area of health most clearly identified with women is of course that of reproductive, sexual and maternal health. In this area, data reveal the significant disadvantages faced by indigenous women in terms of both health outcomes as well as access to health services. Although unsatisfied demand on the part of indigenous women for family planning services has decreased in recent years, a significant percentage of these women still encounter a lack of coverage of such reproductive health services. For example, in Guatemala, whilst it is the case that data confirm a noticeable decline in the unsatisfied demand on women for family planning services between 2002 (39.3 per cent) and 2008 (29.6 per cent), this decline was less than among non-­indigenous women, hence ethnic inequalities have in effect increased. Similarly, in the case of Mexico in 2009, 21.5 per cent of indigenous women expressed an unsatisfied demand for family planning services, compared to 9 per cent of non-­indigenous women. Indeed, in the state of Guerrero, indigenous women’s unsatisfied demand for family planning services was as high as 36.3 per cent, triple that of non-­indigenous women (13 per cent). On the other hand, indigenous women proportionately use more traditional contraceptive methods, such as periodic abstinence or rhythm, withdrawal, the Billings ovulation method, toroidal collars, and other unspecified techniques in accordance with folk wisdom (CEPAL et al., 2013). In Latin America, the proportion of young mothers in the indigenous population is also higher than that of the non-­indigenous population. Countries with the greatest disparity between indigenous and non-­indigenous adolescents who are mothers are Brazil (27 per cent compared to 12 per cent of all adolescent girls), Costa Rica (30 per cent compared to 12 per cent), Panama (37 per cent compared to 15 per cent) and Paraguay (45 per cent compared to 11 per cent), respectively. These stark differences evidence the unequal access to the right to sexual and reproductive health due to a variety of structural causes, including the fact that in almost all countries of the region, educational opportunities for young indigenous women are fewer than among the rest of the population (see below on access to formal education disaggregated by sex from selected countries), affecting their access to health information and life opportunities in general; that a great number live in rural areas with restricted access to health care; and the lack of culturally appropriate health services, which make it difficult for these young people to access family planning services (CEPAL and UNFPA, 2009). Above and beyond the health and well-­being risks of adolescent pregnancy, it is well known that rates of maternal mortality are greater among indigenous women. For

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62  Handbook on gender and health example, in Mexico, data confirm that the risk of indigenous mothers dying is up to nine times higher in municipalities that are predominantly indigenous, particularly those with a very high index of ostracization and geographical and social isolation, compared to municipalities that have better communication with the outside. In Panama, estimates from 2008 registered a maternal mortality ratio of 71 deaths per 100 000 births, reaching 344 in the Ngöbe-­Buglé Region. In Honduras in 2004, in the departments where the greatest indigenous population is concentrated (Columbus, Copán, Intibuca, Lempira and La Paz), the maternal mortality ratio ranged from 190 to 255 deaths per 100 000 live births, while the national average was 147 (CEPAL et al., 2013). In Brazil, the maternal mortality rate among indigenous women was almost double that of non-­indigenous women (113 and 68 per 100 000 live births, respectively) (PAHO/WHO, 2013). In addition, although reliable data on unsafe abortion as an indirect cause of maternal mortality in the region are not readily available for obvious reasons, a greater incidence of unsafe abortions and unwanted pregnancies has also been observed among indigenous women and is likely to contribute to maternal mortality. In Mexico, the risk of indigenous women having an abortion in unsafe conditions is up to five times greater than amongst the general population (Sousa et al., 2010). Although it is generally accepted that prenatal check-­ups cannot always prevent many of the most common causes of maternal mortality which occur as obstetric emergencies, data on access to prenatal check-­ups also reveal huge gaps between indigenous pregnant women and the rest of the expectant population. Data from seven countries where information was available show, for example, that indigenous pregnant women in Panama are 4.5 times more likely to have no prenatal check-­ups than are non-­indigenous pregnant women (23.1 per cent and 4.2 per cent, respectively) and the percentage of indigenous women who have at least one prenatal check-­up ranged from 61 per cent in Ecuador to 88.4 per cent in Brazil (CELADE, 2010). Very often these profound inequities in access to reproductive health, particularly prenatal care, are emphasized in terms of the negative implications for children, which are of course of vital importance. However, it is also crucial from a human rights perspective to focus upon these issues in terms of indigenous women’s own rights to reproductive health and autonomous choice, an issue which, particularly in the Latin American context, can become fraught with political and religious tensions (Alvarez Minte, Chapter 28 in this Handbook; Morgan, Chapter 27 in this Handbook). Nutrition That said, poor nutrition is one of the health issues that most affects indigenous peoples around the world and this is one particular area of particular concern with respect to indigenous children, with rates of malnutrition for indigenous children in Latin America double that of the general population of the region (DESA, 2009). In addition to circumstances of extreme poverty, indigenous peoples suffer from malnutrition because of environmental degradation and contamination of the ecosystems in which indigenous communities have traditionally lived, loss of land and territory, and a decline in abundance or accessibility of traditional food sources. These changes in traditional diet, combined with other changes in lifestyle, have resulted in widespread malnutrition among indigenous peoples. This malnutrition, however, manifests itself differently depending on

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Towards a new political agenda for indigenous women’s health  ­63 the local circumstances. While in some parts of the world malnutrition affects maternal and infant health and child development, in other regions it contributes to an increasing prevalence of non-­communicable diseases such as obesity, diabetes and cardiovascular disease among indigenous peoples (DESA, 2009). Indigenous children under five have a risk up to five times greater than non-­indigenous children of suffering from chronic malnutrition (in Panama, 56.4 per cent and 11 per cent, respectively). Their risk of being underweight is up to 4.5 times greater (in Panama, 10.9 per cent and 2.4 per cent, respectively). They face up to twice the risk of acute malnutrition (in Peru, 1.6 per cent and 0.8  per cent, respectively) (CELADE, 2010). Although data disaggregated by sex are unfortunately not readily available, many of these are clearly issues which equally, if not yet more significantly, affect indigenous women, given their nutritional needs during pregnancy, for instance, and what we know with regards to the gendered dynamics of unequal intra-­household distribution of resources in indigenous and non-­indigenous households in the region, including food (Tolhurst et al., Chapter 23 in this Handbook). Violence Against Indigenous Women One clear area of concern with regards to indigenous women’s health is that of violence against women, which is not only a violation of women’s human rights but also, since 1994, recognized as an issue of public health by the World Health Organization. It is difficult, however, to obtain reliable and timely information on violence against women, especially indigenous women. On the one hand, to date, reporting forms, registries and surveys rarely, if ever, include a field to identify the victim’s ethnicity. On the other hand, statistical instruments do not normally undergo any cultural adaptations that take into account the needs and perspectives of indigenous women or that make it easy for them to report cases of violence. Nevertheless, based on the information available, data show that around 38 per cent of all indigenous women in Ecuador and Peru have suffered physical or sexual violence from their partner at some point in their life. The same is true for as many as 24 per cent of indigenous women in Guatemala and 20 per cent in Paraguay (CEPAL et al., 2013). Mental Health and Suicide Alongside violence, perhaps one of the gravest and emotive examples of health inequities on the basis of ethnicity is that of suicide. Mortality from suicide is greater among indigenous peoples than among the rest of the population. In Chile, self-­inflicted mortality among the indigenous population ranged from 11.8 (per 100 000 inhabitants) in Iquique to 55.0 in South Araucania; while among the non-­indigenous population it ranged from 6.8 to 17.5 in Arica and South Araucania, respectively (US Public Health Service, 1999). This has clear parallels to the neighbouring United States, where it is a known fact that Native Americans in Alaska suffer a higher prevalence of depression and substance abuse (US Public Health Service, 1999). It is also widely known that they have less access to mental health services, do not receive as high-­quality care, and remain underrepresented in mental health studies. There is, unfortunately, a lack of sex-­disaggregated data on suicide and, although it would perhaps be easy to draw conclusions with regards to linkages with other health inequities mentioned earlier in

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64  Handbook on gender and health this chapter, such as a­ dolescent pregnancy, unmet family planning needs and violence against women, relatively little research has examined directly the mental health status and treatment needs of the indigenous peoples of the world, specifically that of indigenous women when addressing suicide, and much more investigation in this area is urgently needed. Communicable Diseases (TB and Malaria) One health issue about which much more is known, however, is tuberculosis (TB), known as the ‘disease of poverty’, and in Latin America primarily affecting indigenous peoples. For example, in eight selected health facilities in Chile, incidence rates for TB among the indigenous population range from 8.7 (per 100 000 inhabitants) in Iquique to 52.7 in Osorno; while among the rest of the population receiving care at the same health facilities, they range from 1.2 to 17.5. In Paraguay in 2010, the relative risk of the indigenous population of developing TB was 10.7 times that of the rest of the population (OPS et al., 2015). Although in fact indigenous men are proportionately more at risk than indigenous women, given the overall levels of prevalence amongst indigenous populations, indigenous women are also disproportionately at risk. Like many other communicable diseases, malaria also affects indigenous peoples disproportionately, in particular in the Amazon Region of South America as a result of malaria vectors there being closely associated with forests, where the majority of indigenous peoples in that area live. Here gender intertwines with ethnic inequalities in terms of both structural and biological determinants, as malaria infection during pregnancy is a significant public health problem with substantial risks for pregnant women, the foetus and the newborn child. Malaria in pregnancy also contributes to significant perinatal morbidity and mortality, and infection is also known to cause higher rates of miscarriage, intrauterine demise, premature delivery, low-­birth-­weight neonates and neonatal death.

INDIGENOUS WOMEN’S ACCESS TO ‘QUALITY’ HEALTH SERVICES IN LATIN AMERICA It is clear that at the heart of these ethnic inequalities in health outcomes lie not only structural inequalities in terms of the social determinants of health, but also a severe crisis in terms of access to quality – culturally appropriate – health services. Across Latin America, inequalities of access to health services, particularly quality health services, have long been an issue for concern, especially in the discrepancies between rural and urban areas and between lower-­and higher-­income populations, and geographical barriers combine with the direct and indirect costs of accessing care. Given that indigenous populations are often disproportionately represented in rural, often remote, locations across the region, as well as amongst those living in situations of poverty and indigence, these barriers clearly significantly impact upon their possibility to access care. Poverty measurements, particularly those applying a multidimensional approach to measurement (Coates, 2010b), consistently reveal higher levels of income inequity as

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Towards a new political agenda for indigenous women’s health  ­65 well as social exclusion and lesser access to basic needs among rural populations and among indigenous populations in the region. Although ethnicity is not consistently and routinely gathered, in 15 countries where data were available, differences in the incidence of poverty between indigenous and non-­indigenous populations were observed in Bolivia (1.3 times greater); and the greatest disparities were observed in Chile (4.3 times), Ecuador (3.4 times) and Paraguay (2.6 times) (CEPAL, 2006). In addition, indigenous women are less likely to have access to their own income and/or control over household assets to meet the costs of care, and frequently are not empowered to take relevant ­decisions with regards to accessing care. As well as economic barriers to accessing care, especially where out-­of-­pocket payments are significant and/or particularly regressive in nature, language barriers also represent a barrier to access to health services in particular in the face of indigenous women’s lower levels of education (as mentioned earlier in this chapter) and bilingualism in indigenous and official languages. Despite progress made in providing opportunities for accessing formal education, there is nonetheless a persistence of ethnic, generational and gender inequalities. In 2000–2012, access to educational facilities notably increased for indigenous girls and boys, adolescents and young adults aged 6–22. According to census data collected from five countries (Brazil, Costa Rica, Ecuador, Mexico and Panama) around 2010, in most of these countries more than 90 per cent of indigenous boys and girls were enrolled in school. In Brazil and Colombia, however, school enrolment rates for indigenous boys and girls were substantially lower than for non-­indigenous children. More than 70 per cent of indigenous adolescents aged 12–17 were enrolled in school, but for adolescent girls enrolment rates ranged from 58.2 per cent to 84.1 per cent; and among adolescent boys from 59.3 per cent to 87.2 per cent. Among indigenous young adults aged 18–22, in no country does enrollment exceed 40 per cent (CEPAL et al., 2013). Racism and other forms of discrimination are also widespread, creating a substantial barrier to indigenous peoples’ access to health services (DESA, 2009). Although the available information does not allow for systematically analysing the access to, and utilization of, health resources by indigenous peoples, differences among the various peoples and populations are observable. In Bolivia, for example, the indigenous population stated that they had been ill more often than did the non-­indigenous population (19.4 per cent and 15 per cent, respectively). Despite this fact, indigenous peoples reported having sought health care less than did their non-­indigenous counterparts (46 per cent and 58.7 per cent, respectively). When able to access care, available health services are often of a poorer quality than those available in other contexts (UNICEF, 2012). In addition, those health services available are frequently at odds with the different paradigms of health and illness applied by indigenous peoples. Although evidence shows that indigenous peoples frequently implement pragmatic strategic and multiplistic (‘healer-­hopping’) strategies of accessing both systems of health care, taking a variety of factors (including financial and geographical costs) into account, it is also the case that certain health and well-­being practices (such as those related to birthing practices) are fundamental to ethnic identity construction and maintenance and to spiritual belief systems. Thus, an expansion of the concept of quality health services is necessary, to include cultural acceptability, appropriateness and, ideally, intercultural approaches to health (PAHO/WHO, 2006).

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66  Handbook on gender and health

EXISTING NORMATIVE FRAMEWORKS ADDRESSING INDIGENOUS WOMEN’S HEALTH IN LATIN AMERICA Hence, the health issues facing indigenous women are complex and not easily addressed without specific intervention strategies, both from within the health sector as well as in conjunction with other intersectoral interventions addressing social determinants (Coates, 2010a) formulated on the basis of principles of participation and inclusiveness. Political will to implement such strategies, and indeed break the vicious cycle of data, evidence and action noted in the introduction to this chapter, has to date been varied and often lacking. One of the key ways, however, to generate such political will, and to mandate governments to formulate and implement strategies that specifically address indigenous women’s right to health, is the existence of normative frameworks at global and regional levels. Normative frameworks are, as Alkire and Deneulin (2009) note, particularly important as a means of shaping policy, and thus shaping people’s lives and experiences. They ‘shape the data we collect; they influence our analysis; they give certain topics greater or less political salience; they feed or stymie social movements; they may motivate professionals for moral or ethical reasons and they can be more or less philosophically credible’. In short, they can operate as frameworks that, usually through a complex and highly politicized process of negotiation and agreement, can draw together disparate political positions into a unified value framework to galvanize governments on, and hold them accountable for, certain shared priority areas of action for the benefit of individuals, societies and the increasingly interconnected world as a whole. The extent to which such frameworks can make a difference, however, often depends upon the strength of ownership and identification any particular national government feels over the values and objectives contained within them, and thus the likelihood of implementing policies and programmes at national levels that aim to fulfil the commitments. Binding intergovernmental agreements, which include clear accountability mechanisms, are therefore of the utmost importance to ensure optimal results. Global Frameworks It is unfortunately safe to say that current normative frameworks, both binding agreements and otherwise, have been largely silent on the specificities affecting indigenous women’s right to health. Nevertheless, useful related precedents exist which, in one way or another, have begun to make inroads into the issue, albeit principally in terms of linkages with other issues and/or within the context of broader frameworks that can be applied to the issue. The most commonly referred-­to document with respect to indigenous peoples is the United Nations Declaration on the Rights of Indigenous Peoples (13 September 2007). The Declaration establishes a universal framework of minimum standards for the survival, dignity, well-­being and rights of the world’s indigenous peoples. The Declaration addresses both individual and collective rights; cultural rights and identity; rights to education, health, employment, language; and others. It outlaws discrimination against indigenous peoples and promotes their full and effective participation in all matters that concern them. It also ensures their right to remain distinct and to pursue their own

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Towards a new political agenda for indigenous women’s health  ­67 ­ riorities in economic, social and cultural development. In addition, the Declaration p explicitly  encourages harmonious and cooperative relations between states and indigenous peoples. With regards to health, the rights of indigenous peoples to maintain their own traditional, ancestral or community medicines, as well as to maintain their own health practices, is protected in Article 24 of the Declaration. The latter establishes the importance of indigenous peoples’ own knowledge and health practices in forming part of cultural heritages and being consistent with different world views and conceptualizations of our relationship to nature. The Declaration has clearly been groundbreaking, providing a long-­needed public policy reference paper for actions to be undertaken by those states whose populations include indigenous communities within their territories, with the basis for all such actions being the principles of respect for diversity, assessment, recognition of wisdom, the need to preserve traditional knowledge, and above all the freedom of indigenous peoples to live life according to their own world view, values and beliefs. However, the Declaration is not without its drawbacks, particularly in relation to the promotion of women’s rights. Certain crucial issues are arguably not adequately addressed within the Declaration, in particular the issue of the tension between individual rights, especially women’s rights, and cultural and community rights. Although the Declaration defines indigenous peoples’ rights to target the discrimination that indigenous individuals face, it does not refer to the discrimination within the community. Indeed, debates have focused on whether the recognition of the right to self-­determination by international human rights law lends protection to certain indigenous cultural practices that result in illegitimate gender inequalities. It is also important to note that the Declaration on the Rights of Indigenous Peoples, whilst of a significance not to be underestimated in terms of a political statement at global level and a policy reference point at country levels (as noted above), is not a binding normative framework, meaning that it does not serve a mandate for a United Nations (UN) member state’s action and accountability. In that sense, then, the most relevant binding normative frameworks until recently have included the Convention on the Elimination of All Forms of Racial Discrimination (1963) (CERD), and especially the General Recommendation No. 23 Indigenous Peoples (1997), which reaffirmed that the provisions of the Convention apply to indigenous peoples, and the Convention on the Elimination of All forms of Discrimination against Women (1979) (CEDAW), Article 12 of which focuses upon Women and Health. Furthermore, in relation to the latter article, CEDAW General Recommendation (GR) No. 24, made in 1999 during the Committee’s twentieth session, refers specifically to indigenous women in the context of the ‘special attention [that] should be given to the health needs and rights of women belonging to vulnerable and disadvantaged groups’ (par. 6, Background); the necessity for health legislation, plans and policies to ‘take into account any ethnic, regional or community variations or practices based on religion, tradition or culture’ (para. 9: 1); and in ­paragraph 22, the Committee refers to quality health care services, defining ‘acceptable services [as] those which are delivered in a way that ensures that a woman gives her fully informed consent, respects her dignity, guarantees her confidentiality and is sensitive to her needs and perspectives’. The Committee on the Rights of the Child has also dedicated its General Comment

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68  Handbook on gender and health (GC) No. 11 (2009) to indigenous children and their rights under the Convention. In this regard, a section of GC No. 11 on ‘Basic Health and Welfare’ addresses, among others, suicide and adolescent health, referring specifically to access to sexual and reproductive information and services, including on family planning and contraceptives, and the dangers of early pregnancy. Such references to indigenous peoples – and, specifically, indigenous women’s health – within these broader mandates at the global level have proved an essential tool for the promotion of relevant action in countries. That said, however, they are limited in their potential to offer the detail and depth required to address the specificities of issues facing indigenous men and women in ways that can be implemented in dedicated legislative frameworks, policies and programmes at national levels. One binding framework which is focused more specifically on indigenous peoples is the International Labour Organization (ILO) Convention 169. However, health is not a prioritized issue in this Convention (education and land are among the issues given priority, comprising a total of 13 articles in Parts II and VI, respectively). Mention is made of health in Article 7, which stipulates that economic development should be undertaken with the full consent and involvement of indigenous peoples and in the interest of improving their conditions of life, including the standards of health and education they enjoy. The specific articles on health, Articles 24–25, are found in ‘Part V: Social Security and Health’. The first of these articles provides for the progressive establishment of social security schemes; and the second, for an array of health services to be accessible and culturally appropriate to indigenous communities. Until recently, the above documents have been the key points of reference for legislative frameworks, policy and action to advance the rights of indigenous peoples. However, the World Conference on Indigenous Peoples (WCIP), held at the United Nations General Assembly in September 2014, provided an undeniable impetus not only to the visibility of the issue on the world stage and the political will for addressing it, but also, in its agreed Outcome Document, to the provision of a global normative framework that sets out clearly the details of a mandate for action. At its core, the Outcome Document reiterates the UN Declaration on the Rights of Indigenous Peoples to consult and cooperate in good faith with the indigenous peoples concerned through their own representative institutions in order to obtain their free, prior and informed consent before adopting and implementing legislative or administrative measures that may affect them. The Document also focuses on the rights of indigenous women and addresses the problem of violence against women, youth and the challenges they face, from the difficulty in sustaining indigenous languages to preserving traditional knowledge and ensuring sustainable livelihoods. The Document also refers to the importance of indigenous peoples’ health practices and their traditional medicine and knowledge. Paragraph 13 of the Document refers specifically to the highest attainable standard of physical and mental health for indigenous individuals. It considers efforts to reduce rates of HIV and AIDS, malaria, tuberculosis and non-­communicable diseases by focusing on prevention, including through appropriate programmes, policies and resources for indigenous individuals. Reference is also made to ensuring access to sexual and reproductive health and reproductive rights in accordance with the Programme of Action of the International Conference on Population and Development, the Beijing Platform for Action and the outcome documents of their review conferences.

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Towards a new political agenda for indigenous women’s health  ­69 The substantial presence of indigenous peoples from the Latin American region at the 2014 World Conference on Indigenous Peoples provided a notable visibility of the significance of the issue in the region. Indeed, the Lima Declaration (emanating from the World Conference on Indigenous Women, Lima, 2013, and with key leadership from the Latin American region) is widely recognized to have been a central point of reference for the outcome document of the WCIP. It made reference, among others, to the multiple forms of discrimination that indigenous women and girls experience, the lack of access to education and health care, and high rates of poverty and maternal and child mortality. It also very significantly recognized the importance of sexual and reproductive health and education for all ages. Regional Frameworks In addition to the normative frameworks at the global level, regional-­level intergovernmental mechanisms for the advancement of gender equality and women’s empowerment, and resultant consensus documents, are particularly strong and often progressive, including the Inter-­American System for human rights, and the Belem do Pará Interamerican Convention for the Prevention, Sanctioning and Eradication of Violence against Women, as well as the consensus documents emanating from the regular Regional Conference on Women in Latin America and the Caribbean. The latter is the region’s leading intergovernmental mechanism for gender equality convened by the Economic Commission for Latin American and the Caribbean (ECLAC). Gathering together high-­level representatives of 44 member states, eight associated members and other key actors, conferences have led to significant regional agreements. These consensuses, in conjunction with the other intergovernmental mechanisms mentioned above, have had a significant impact in the region in promoting gender equality and women’s empowerment, at least at the level of policy and legislation (although significant challenges remain in ­implementation). Many countries benefit from advanced legal frameworks for women’s rights with, for example, relatively advanced laws against domestic violence and some countries with second-­generation laws that recognize other types of violence and promote public policies for comprehensive health care for those who have experienced violence. Latin  America has also been a leader in the passage of laws and policies to promote women’s political participation, and countries continue to review and improve their legislation, including by improving quota systems and legislation supporting parity. Although the agreements are not binding, the Gender Equality Observatory for Latin America and the Caribbean, agreed at the 2007 Quito Conference, serves an important purpose in analysing and highlighting the progress of countries on an agreed set of indicators on many of the issues noted in the various consensus documents. Although not having a particularly central focus on health, nor on indigenous women, both these issues have been gaining a somewhat greater degree of prominence in the last three such conferences in particular. For example, in the 2007 Quito Consensus, health concerns, whilst not foregrounded (with greater attention being given to the issue of women’s unpaid work, the sexual division of labour more broadly, and to strengthening women’s political participation), are mentioned. In the Preamble, health is mentioned in point 11 in the context of recognizing women’s contributions to productive and reproductive economies and to the well-­being of their communities; in point 18 in the context

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70  Handbook on gender and health of condemning all forms of violence against women; and in point 23, a robust statement is included on gender inequality and women’s health outcomes. These articles highlight a range of health issues, including sexual and reproductive health, violence against women, and the economic and environmental determinants of health. Special mention is made of indigenous women, among other minority and vulnerable groups, with regards to the additional barriers they face to the enjoyment of health and exercise of sexual and reproductive rights. In the outcome of the 2010 Regional Conference (the so-­called ‘Brasilia Consensus’), health concerns occupy a much more central place. In the Preamble, as well as again emphasizing issues of violence against women, attention is drawn to women’s right to comprehensive health care (with gender inequality recognized as one of the social determinants of health, to be considered alongside environmental and biological factors) (p. 3) and maternal mortality and morbidity (p. 4). In the body of the Consensus, indigenous women’s health needs are situated within Section 4, on addressing and eradicating all forms of violence against women, and, centrally, in Section 6 on promoting the conditions for the integral health of women and for their sexual and reproductive rights. From this section, Article (i) explicitly addresses the need for intercultural health services that respect and incorporate the traditions practiced by indigenous and Afro-­descendent communities. The Santo Domingo Consensus (2013) has a yet greater focus, with two robust sections dealing with health: Section C, on sexual and reproductive health; and Section D, on the elimination of violence against women. In addition, Article 8 and Article 20 of the Preamble refer specifically to health and, in the latter case, to positioning health in the post-­2015 development agenda. Article 8 mentions health in terms of women’s physical autonomy, understood as ‘control over their own bodies, comprehensive health and . . . right to live a life free from violence’ (p. 2). Physical autonomy is placed alongside women’s economic autonomy and autonomy in decision-­making, as essential to guaranteeing their enjoyment of human rights. The text of Article 20 (p. 3) positions sexual and reproductive health as a priority issue for health in the post-­2015 development agenda. Of the 16 articles under Section D, two make explicit mention of indigenous women. Article 80 stipulates the need to enforce national and local policies and adopt preventive, punitive, protection and care measures to eliminate all forms of violence and stigma against women, girls, adolescent girls, young women, older women, indigenous and Afro-­descendent women, rural women, LGBTI (lesbian, gay, bisexual, transgender and intersex) persons and women with disabilities, and include the effective use of information and communications technologies with an intercultural approach in order to achieve greater inclusion and equality for all women. Both in the Santo Domingo and the Brasilia Consensus, issues of sexual and reproductive health receive particular attention, with specific clauses related to indigenous women. However, the Santo Domingo Consensus accounts for a wider array of vulnerable groups, including sexual minorities and refugees and displaced persons, and it is encouraging to note that universal access to comprehensive health services is stressed alongside the need for culturally appropriate services, since the latter requirement is c­ritical to ensuring quality of care for indigenous peoples. One of the strongest normative mandates for the rights of indigenous peoples at regional level, however, comes from the Inter-­American System, which has a rich body

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Towards a new political agenda for indigenous women’s health  ­71 of jurisprudence related to indigenous peoples, emanating from its interpretations of the American Declaration on the Rights and Duties of Man and the American Convention on Human Rights. Related bodies have interpreted human rights of general application to affirm the rights of indigenous peoples to lands, territories and natural resources; consultation and free, prior and informed consent; political participation; and right to life, among others. Within the Inter-­American System, the Commission and the Inter-­ American Court of Human Rights have issued resolutions and recommendations based on Inter-­American System human rights instruments for the States to follow. Within the framework of the Organization of American States (OAS), the rights of indigenous peoples have received growing attention on the part of governments, as is apparent in a number of relevant declarations. Of greatest significance, on 5 June 2013, the General Assembly of the Organization of American States adopted the Inter-­American Convention against Racism, Racial Discrimination and Related Forms of Intolerance, as well as the Inter-­American Convention against All Forms of Discrimination and Intolerance. With the adoption of both Conventions, OAS member states concluded the task begun in the year 2000, when its General Assembly commissioned the Permanent Council to study the need to put together a project for elaborating a draft Inter-­American Convention to Prevent, Punish, and Eradicate Racism and All Forms of Discrimination and Intolerance (OAS, 2013). Of more specific relevance to health, member states of the Pan American Health Organization, the Regional Office of the World Health Organization for the Americas (hereafter: PAHO/WHO), have also led the way in devoting attention to indigenous peoples’ rights. In September 1993, the PAHO/WHO’s 37th Directing Council passed Resolution CD37.R5, ‘Health of the Indigenous Peoples of the Americas’, which recognized the deficits in both living conditions and health among the indigenous peoples of the Americas. The resolution aimed to implement the Health of the Indigenous Peoples Initiative of the Americas (called SAPIA, taken from its acronym in Spanish), urging governments to formulate policies and strategies geared towards specific indigenous populations, in order to ensure their greater access to high-­quality health services and care and thus contribute to improved levels of equity. In 1997, this commitment was reiterated when the PAHO/WHO’s 40th Directing Council passed Resolution CD40.R6, which again recognized the ever-­increasing inequity in the health status and access to basic health services of the indigenous peoples of the Americas. Much more recently, in 2006, the PAHO/WHO’s 47th Directing Council passed Resolution CD47.R18, ‘Health of the Indigenous Peoples in the Americas’. It recognized the progress made by the SAPIA initiative, while acknowledging the persistence of inequities in access to health services that affect between 40 and 50 million individ­uals from indigenous populations living in the Region of the Americas. It considered the Millennium Development Goals (MDGs) impossible to achieve without meeting the specific health needs of such excluded groups as indigenous populations, and proposed specific lines of remedial action to member states, including the incorporation of an intercultural approach in national health systems and medical personnel training, and the improvement of information related to health issues facing indigenous populations, reiterating its 2003 recommendations on ‘Ethnicity and Health’ that had emphasized the importance of collecting health data on ethnic groups and introducing an ethnic v­ ariable

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72  Handbook on gender and health into national statistics as an instrument to formulate ethnically sensitive policies and programmes. In 2010, PAHO/WHO member states approved Resolution CD50.R8, ‘Health and Human Rights’ (PAHO/WHO, 2010). It recognized that the human rights instruments of the United Nations and Inter-­American systems are useful for the progress of the member states towards the achievement of the MDGs. Its concept paper, CD50/12, specifically refers to ethnic minorities among the groups living in a situation of vulnerability. Yet more recently, PAHO/WHO member states approved Resolution CD53.R14, ‘Strategy on Universal Access to Health and Universal Health Coverage’, which specifically refers to ethnicity as essential to the core principles and aims of universal care and access (PAHO/WHO, 2014). This Strategy reaffirms the commitment stated in the Alma Ata Declaration (1978) and ‘Health for All’ in 2000 and is in concordance with the proposed Sustainable Development Goals, which explicitly state the intention of ‘no one left behind’ (see below). The Strategy considers gender, ethnicity, age, and economic and social status as specific social determinants that have a potentially positive or negative impact on health inequities. These PAHO/WHO resolutions have been groundbreaking and, in their specificity to issues pertaining to the health of indigenous peoples, of overriding significance in the region. However, the specific issues related to indigenous women’s health are still perhaps not so central to the agenda as may be hoped. In addition, for all the clear political will demonstrated by the Ministries of Health, in such resolutions it is important to remember that the PAHO/WHO’s key constituencies are the Ministers of Health and, as such, there are often limitations to the further reach of these resolutions beyond the health sector and, in particular, to formulate the intersectoral initiatives required to address the social determinants of health status and access to health. For these to have a mandate, broader-­ranging normative frameworks are clearly required in conjunction with these more specific and tailored resolutions. Implementation of Normative Frameworks in National Legislative Frameworks and Policies Such limitations are evident in terms of the limited impact the existing normative frameworks have had to date on national legislation and policies in the Latin American region, despite some notable successes. In Guatemala, for example, Decree 32-­2010 approved the Law on Healthy Motherhood (Ley para la Maternidad Saludable, aprobada por Decreto Num 32-­2010) and dialogues, particularly with indigenous midwives, have helped to develop a guide on vertical childbirth care as well as other norms and regulations to attend indigenous mothers. The law makes specific reference to the Convention on the Elimination of Discrimination against Women (CEDAW) as a human rights instrument ratified by the country, and includes respect to diversity among its guiding principles (Article 4). It establishes that the delivery of maternal and neonatal health services must respect and respond to the cultural identities, values and customs of communities. Furthermore, Article 13 of this law recognizes intercultural maternal houses (Casas maternas con pertinencia cultural), which should be designed to allow pregnant women to stay until the moment of delivery. Government Accord 65-­2012 (Acuerdo Gubernativo No 65-­2012) approves the regulation for such law.

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Towards a new political agenda for indigenous women’s health  ­73 However, despite these successes and a turning tide led by certain countries, specific attention to the issue of indigenous women’s health has not been consistent and has been limited in its impact, also suggesting problems with institutional capacity, budgeting and accountability. In Ecuador, for instance, the Ministry of Health has a Human Rights, Gender and Inclusion Directorate. The country has prioritized training of midwives, based on, among other norms, what is set out in Article 363 of the Constitution of Ecuador, which obliges the state to guarantee ancestral medicinal practices through the recognition, respect and promotion of their knowledge, medicine and instruments. The Ministry of Health developed the ‘Guide for Adequate Childbirth Care with an Intercultural Focus’. However, it does not specifically recognize indigenous women, except for the right to ‘culturally-­relevant childbirth’. Furthermore, the Committee on the Elimination of All Forms of Discrimination against Women (CEDAW), during the February 2015 consideration of the eighth and ninth combined periodic reports of Ecuador, expressed concern with regards to the barriers faced by indigenous women in accessing health services that answer their needs and respect their health approaches, including in relation to the practice of vertical births. Indeed, the Committee recommended the State of Ecuador to adopt the draft law on intercultural practice for assisted births under the National Health System with the aim of recognizing intercultural labour care (OHCHR, 2015a). The lack of a legislative framework in Ecuador is consistent with the lack of a regulatory framework or specific laws aimed at improving the health of indigenous women in many countries across the region. Although there are independent initiatives to improve the right to health and other related human rights of indigenous women, most of these initiatives focus primarily on reproductive rights. Since the end of the 1990s, Latin American countries have gone through changes in their health policies and, in some cases, included provisions on intercultural health and universal health coverage as a right. However, it is increasingly clear that this recognition needs to be extended to indigenous peoples and make specific reference to the rights of indigenous women and girls.

A NEW NORMATIVE FRAMEWORK FOR A NEW ERA? From the MDGs to the SDGs Considerable challenges, therefore, remain with respect to ensuring that national legislative frameworks and policy and programmes formulated upon their basis respond adequately to the needs and rights of indigenous women to health. It was noteworthy that the Millennium Development Goals (MDGs) were a significant catalyst for national policies, and accountability, in terms of the normative framework for action that they represented and the simplicity of their objectives and targets may have played a role in the ease in which they were translated into national development goals. They have, however, also been criticized for this very simplicity, which excluded many key areas related to gender equality, categorized development goals rather than emphasized their interdependence, and allowed little space for ensuring approaches based upon principles of human rights and equality, including as a striking absence, inequalities on the basis of ethnic ­inequalities. In effect, therefore, they failed to fully address the values and

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74  Handbook on gender and health ­ rinciples outlined in the Millennium Declaration, particularly in relation to human p rights and equality. In part, these exclusions and limitations have been blamed on the process of creating the MDGs, commonly asserted to have been ‘top-­down’. In contrast, the process for the creation of consensus over the post-­2015 development agenda, the SDGs, was deliberately participatory and inclusive, with face-­to-­face consultations in more than 100 countries, and millions of citizen inputs on websites. Civil society was well organized throughout, coordinated globally through the Beyond 2015 campaign. Alongside the deliberations of the high-­level Open Working Group, the UN conducted a series of ‘global conversations’, which included 11 thematic and 83 national consultations, and door-­to-­door surveys. It also launched an online My World survey asking people to prioritize the areas that should be addressed in the goals. The results of all these consultations were designed to feed into the Working Group’s proposal, which looked strikingly different from the MDGs in terms of its broad reach and specificity of approach within each of the 17 proposed goals. In contrast to the eight MDGs, there are 17 SDGs that go beyond the symptoms of poverty, to issues of peace, stability, human rights and good governance. The goals include Goal 3: ‘Ensure healthy lives and promote well-­being for all at all ages’, which includes targets related to specific issues such as maternal and infant mortality, reproductive health and communicable diseases, and others as well as more institutional issues such as coverage and access to essential services and medicines, health and well-being and one on gender equality. Goal 5: ‘Achieve gender equality and empower all women and girls’ also goes significantly further than MDG 5, including targets related to ending discrimination and violence against women, recognition of unpaid work, equal access to economic resources and sexual and reproductive health and reproductive rights, and others. Mainstreaming or a Targeted Approach to Indigenous Women’s Health? Operationalizing Gender Equality and Human Rights The SDGs then are certainly wide-­ranging in terms of the breadth of the issues covered, including many areas relevant to different forms of inequalities and development, and the far more prescriptive nature of their policy recommendations. Nevertheless, fully addressing inequalities in the post-­2015 development agenda implies a focus upon both equality of opportunities and outcomes (or lack thereof), and entrenched structural factors, that perpetuate various forms of inequalities, such as discrimination, marginalization and social and economic exclusion based on ethnicity, gender, age, location, and others. Arguably here the SDG agenda, as wide-­ranging as it is, fails because references to such inequalities, in particular ethnic inequalities, are practically absent across all the focus areas, including within the health and gender goals. In many senses the challenges of incorporation of the specificity of issues related to indigenous women’s health also apply to other cross-­cutting themes, particularly in terms of the balance between a mainstreamed approach and one of targeted action. This is clear in the significant impetus that has been given to gender equality and women’s empowerment in the agenda, with a much wider-­ranging goal than included in the MDGs. This targeted approach, however, has perhaps been at the expense of emphasizing the centrality of gender equality to all areas of development, including health. Although Goal 3 is

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Towards a new political agenda for indigenous women’s health  ­75 explicitly aimed at health and well-­being for all, the targets within this goal do not make reference to inequities in health outcomes nor to social determinants of health, including those related to gender inequalities, which are at the heart of many inequalities in risk of ill-­health and access to quality health services for indigenous women, as for other marginalized groups and individuals. Nevertheless, some potential does perhaps exist in Targets 3.7, which aims to ‘ensure universal access to sexual and reproductive health care services’, and 3.8, aimed at the ‘achieve[ment of] universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all’. Whilst the latter does not go so far as the PAHO/WHO strategy discussed earlier in this chapter (most notably, not including universal access), the articulation of this target with, particularly, the overreaching targets of Goal 5 on ending all forms of discrimination against women and adopting and strengthening policies and enforceable legislation for the promotion of gender equality and the empowerment of all women and girls at all levels, and the more specifically health related targets, Target 5.2 on eliminating all forms of violence against all women and girls in public and private spheres and Target 5.6 on ensuring universal access to sexual and reproductive health and reproductive rights, could provide a useful framework for action. Similarly, Targets 5.4 on recognizing and valuing unpaid care and domestic work through the provision of public services, infrastructure and social protection policies, and Target 5.a on the necessity of reforms to give women equal rights to economic resources, as well as access to ownership and control over land and other forms of property, financial services, inheritance and natural resources, provide some potential for action on the social determinants of health, and the recognition of the role of informal provision of health care, if taken as a framework for intersectorial action between the health sector and others. Despite this possible articulation, critics of the new agenda have nevertheless argued that the integration of gender concerns has primarily followed the ‘add women and stir’ approach, a superficial approach that ‘does nothing to address the deeply embedded gender power structures that force women, in all their diversity, to bear the heaviest burden of poverty and inequality’ (AWID, 2013). Nevertheless, although this targeted approach is undoubtedly limited in its potential to emphasize the need to interrogate and address gendered inequalities across the development policy spectrum, the need to work towards gender equality is at the very least visible within the agenda. On the other hand, despite calls for the rights and needs of indigenous women to be addressed in the next development agenda, in response to, amongst others, the latest report on the ‘State of the World’s Indigenous Peoples’, the issue is invisible across the thematic goals: Indigenous peoples face systemic discrimination and exclusion from political and economic power; they continue to be over-­represented among the poorest, the illiterate, the destitute; they are displaced by wars and environmental disasters; indigenous peoples are dispossessed of their ancestral lands and deprived of their resources for survival, both physical and cultural; they are even robbed of their very right to life. (DESA, 2009)

Means of Implementation: Data and Participation The one area of the SDGs where ethnic and gender inequalities are highlighted is in relation to Goal 17: ‘Strengthen the means of implementation and revitalize the global

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76  Handbook on gender and health partnership for sustainable development’. Here there is some cause for cautious optimism as, alongside other issues such as financing and capacity strengthening and others, within the targets related to ‘Data, monitoring and accountability’, Target 17.18 calls for ‘enhance[d] capacity building support to developing countries, including for least-­ developed cuntries (LDCs) and small island developing states (SIDS), to increase significantly the availability of high-­quality, timely and reliable data disaggregated by income, gender, age, race, ethnicity, migratory status, disability, geographic location and other characteristics relevant in national contexts’. This inclusion is in response to one of the lessons commonly drawn from the MDGs, namely, the need for the SDGs to provide more disaggregated statistics and analysis to visibilize the most vulnerable and marginalized populations and enhance measurement of inequalities both within and among countries. This inclusion is an essential component needed to match the ambition that ‘no one should be left behind’ and ‘no target should be met, unless met for all groups’ in the new post-­2015 development agenda. Indeed, disaggregated statistics will be key to support tailored and evidence-­based policy formulation, as well as monitoring of the implementation of the development agenda (OHCHR, 2015b) with indicators which measure not only overall impact but which reflect the multidimensional aspects of development (Coates, 2010b) and also the equitable (or inequitable) impacts of development interventions across different population groups. Despite the lack of mainstreaming of gender and ethnic inequalities across the agenda (including within the health and well-­being goal and in relation to the intersection of inequalities), this inclusion as a key mechanism within the means of implementation of the post-­2015 development agenda is perhaps the most groundbreaking departure from the MDGs and step towards addressing the specificities of indigenous women’s health. As emphasized at the beginning of this chapter, the lack of data on indigenous women represents a significant barrier to designing effective interventions that address the inequalities (gendered, ethnic, socio-­economic, and so on) that they face and that hinder their enjoyment and exercise of a full spectrum of human rights. In particular, the lack of health-­related data is a key challenge in the generation of sound evidence-­based policies to effectively address health inequities faced by indigenous women. A note of caution should be expressed here with respect to the process of collecting such data, to ensure that indigenous peoples have full and effective participation, and take leadership roles in the collection, processing, reporting and use of information that guides decision-­making in health policies and programs (DESA, 2009). However, the end result has the potential to take a substantive step forward in terms of visibilizing and addressing the intersecting and compounding nature of inequalities of gender, ethnicity and others in relation to health, of particular relevance to the Latin America region (Coates, 2010a). For this potential to be fully realized, the principle of participation is of relevance across the means of implementation, above and beyond the collection and analysis of data. This is of special significance to the issue of indigenous women’s health because of the existence of cultural barriers to access to quality health care for indigenous women, in combination with the other structural barriers and social determinants (Coates, 2010a). The latter represent a complicated challenge, given that, to date, there is relatively little understanding amongst policy-­makers of the social and cultural factors deriving from the knowledge, attitudes and practices in the health of indigenous peoples that have been passed from generation to generation and have become part of the community

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Towards a new political agenda for indigenous women’s health  ­77 norms. Hence, in implementing the SDGs, it will be important to identify innovative and respectful ways of working together with indigenous peoples to tackle structural barriers to health care with inclusive, participatory and culturally appropriate programmes and policies.

CONCLUSION Therefore, despite notable challenges and limitations related to the absence of mainstreaming of ethnicity across the goals, and the lack of visibility of both gender and ethnic concerns in the health and well-­being goal, the new proposed framework does offer some potential for entering more concretely into commitments related to indigenous women’s health. The key to this potential, however, lies not in explicit references or dictates but rather in the combined commitments of the health, gender equality and governance goals and in a wide-­ranging, interdisciplinary perspective that thinks outside of sectorial boxes and takes into account the ways in which the goals articulate with one another. In particular, the health goals can be interpreted as articulating with other goals on gender equality and women’s empowerment, as well as with the goal on governance, to perhaps provide a useful framework for action to advance indigenous women’s health, if such an analysis is made and an intersectorial approach taken. Nevertheless, whether or not this framework will live up to this potential to draw upon indirect references and the interpretation of particular combinations and interdependencies of targets, and deliver improvements to the lives of indigenous women (particularly in terms of their health status and access to quality, culturally appropriate health care) remains to be seen. It is a political agenda which is fraught with complexity since it implicates challenges to prominent bodies of thought in the areas of both ‘development’ and medical practice. Similarly, the detailed nature of the agenda itself, in contrast to the MDGs’ simplicity, will require more sophisticated means of translation and adaptation to national contexts, a process in which this very potential for interpretation of interdependencies between goals in order to relate them to indigenous women’s health may be dissipated, and particularly in terms of balancing the challenges of individual, cultural and community rights. Nevertheless, the very detail of the SDGs and their targets allows development advocates, development and public health practitioners, promoters of indigenous peoples and women’s rights, and policy-­makers the scope to make the relevant connections and ensure that key issues are made visible on the political agenda, to subsequently improve national legislation and policy frameworks. It only remains to be seen whether this potential is realized to make a genuine difference to the realities of indigenous women’s health in the Latin America region.

NOTE *

The authors are staff members of the Pan American Health Organization. The authors alone are responsible for the views expressed in this chapter, and they do not necessarily represent the decisions or policies of the Pan American Health Organization.

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78  Handbook on gender and health

REFERENCES Alkire, Sabina and S. Deneulin (2009), ‘A Normative Framework for Development’, in S. Deneulin and L. Shahani (eds), An Introduction to the Human Development and Capability Approach: Freedom and Agency, Oxford: Earthscan and International Development Research Centre. AWID (2013), ‘Reflections towards a post-­2015 development agenda: an AWID in-­depth analysis of the post-­ 2015 High Level Panel Report and recommendations moving forward’, available at http://www.awid.org/ Library/An-­AWID-­in-­depth-­analysis-­of-­the-­Post-­2015-­High-­Level-­Panel-­Report-­and-­recommendations-­ moving-­forward. Centro Latinoamericano y Caribeño de Demografía (CELADE) (2010), ‘Procesamientos especiales de encuestas sobre demografía y salud’. CEPAL (2006), ‘Panorama Social de América Latina’, Santiago de Chile: CEPAL, available at http://www. cepal.org/es/publicaciones/1225-­panorama-­social-­de-­america-­latina-­2006. CEPAL, ONU-­Mujeres, UNFPA and OPS (2013), ‘Observatorio de Igualdad de Género de ALC. Mujeres Indígenas en AL. Dinámicas demográficas y sociales en el marco de los derechos humanos’, Chile. CEPAL and UNFPA (2009), ‘Avances y acciones clave para la implementación del Programa de Acción de El Cairo, a 15 anos de su aprobación’, Santiago, available at http://www.cepal.org/publicaciones/xml/5/37385/ DDR4.pdf. Coates, Anna (2010a), ‘Maternal Mortality in Latin America: A Matter of Gender and Ethnic Equality’, in Sylvia Chant (ed.), International Handbook of Gender and Poverty, Cheltenham, UK and Northampton, MA, USA: Edward Elgar Publishing. Coates, Anna (2010b), ‘Multidimensional Poverty Measurement in Mexico and Central America: Incorporating Rights and Equality’, in Sylvia Chant (ed.), International Handbook on Gender and Poverty, Cheltenham, UK and Northampton, MA, USA: Edward Elgar Publishing. Department of Economic and Social Affairs (DESA) (2009), ‘State of the World’s Indigenous Peoples’, New  York: United Nations, available at http://www.un.org/esa/socdev/unpfii/documents/SOWIP/en/ SOWIP_web.pdf. Office of the High Commissioner for Human Rights (OHCHR) (2015a), ‘Committee on the Elimination of All Forms of Discrimination Against Women, 60 session, Concluding Observations to Ecuador’, available at http://tbinternet.ohchr.org/_layouts/treatybodyexternal/SessionDetails1.aspx?SessionID=901&Lang=en. Office of the High Commissioner for Human Rights (OHCHR) (2015b), ‘SDGs indicators framework: A Human Rights Approach to Data Disaggregation to Leave No One Behind’, available at http://www.ohchr. org/Documents/Issues/HRIndicators/DataDisaggregation.pdf. OPS, CEPAL and UNFPA (2015), ‘La salud de los pueblos indígenas y afrodescendientes en América Latina. Boletín estadístico’, WDC. Organization of American States (OAS) (2013), ‘Department of International Law. OAS General Assembly Adopts Conventions against Racism and Discrimination’, Washington, DC: OAS, available at http://www. oas.org/en/sla/dil/newsletter_inter-­American_treaties_jun-­17-­2013.html. Pan American Health Organization/World Health Organization (PAHO/WHO) (2006), ‘CD47/13 of the 47 PAHO/WHO Directing Council, Health of the Indigenous Peoples of the Americas’, available at: http:// www1.PAHO/WHO.org/english/gov/cd/CD47-­13-­e.pdf. Pan American Health Organization/World Health Organization (PAHO/WHO) (2010), ‘CD50/12 and CD50. R8 of the 50 PAHO/WHO Directing Council, Health and Human Rights’, available at http://www2.PAHO/ WHO.org/hq/dmdocuments/2010/CD50-­12-­e.pdf. Pan American Health Organization/World Health Organization (PAHO/WHO) (2013), ‘Base de Datos Regional de Mortalidad’. Pan American Health Organization/World Health Organization (PAHO/WHO) (2014), ‘CD53/5, Rev.2 of the 53 PAHO/WHO Directing Council, Strategy for Universal Access to Health and Universal Health Coverage’, available at http://www.PAHO/WHO.org/hq/index.php?option=com_content&view=article&id=9774&Item id=41062&lang=en. Sousa, A., R. Lozano and E. Gakidou (2010), ‘Exploring the Determinants of Unsafe Abortion: Improving the Evidence Base in Mexico’, Health Policy and Planning, 25, 300–310. UNICEF (2012), ‘Guía de transversalización de la interculturalidad en proyectos de desarrollo: salud, higiene y protección contra la violencia’, Bolivia, available at http://www.unicef.org/bolivia/resources_24854.htm. US Public Health Service (1999), ‘Department of Health and Human Services, Mental Health: a report of the Surgeon General’, available at http://profiles.nlm.nih.gov/ps/access/NNBBHS.pdf.

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5.  Dangerous discourses? Silencing women within ‘global mental health’ practice Rochelle Ann Burgess

INTRODUCTION The mental well-­being of the world’s poorest women has taken centre stage in the wake of a general interest in mental health issues led by the Movement for Global Mental Health (MGMH).1 Women have been argued to be disproportionately affected by mental ill-­health globally: they are twice as likely to experience depression than their male counterparts (WHO, 2015), and display lifetime prevalence rates of anxiety disorders such as panic disorders and phobias up to three times higher than men (Kadri and Alami, 2009). Women face a series of gender-­driven risk factors: they are more likely to be exposed to conditions marked by poverty, violence, conflict, inequality, and face heavy burdens created by responsibilities of caring for others which have known impacts on mental well-­ being (Astbury and Jewkes, 2011; Howard et al., 2010). Though there remains a paucity of evidence from the sub-­Saharan Africa (SSA) region on mental health as a whole (Saxena et al., 2007), a 2004 study calculated prevalence rates for major depressive disorders among women in the African region at 3.5 per cent (Chisholm et al., 2004). In Uganda and South Africa women’s mental health problems are often correlated with adverse social and relational contexts such as poverty, violence and marital conflict (Agardh et al., 2012; Burgess and Campbell, 2014). In light of such studies, there are increasingly urgent calls to extend access to mental health services for women around the world. However, behind the proliferating evidence advocating the best response to women’s mental health needs in low-­and middle-­income settings sits the uncomfortable history of the field of psychiatry’s engagement with women. A vast body of literature articulates the oppression and discrimination that women have faced at the hands of psychiatric practice from the earliest days of the field’s history (see Appignanesi, 2011; Ussher, 2010). As such, psychiatry’s approach towards women has faced much scrutiny from Western feminist theorists and practitioners (Stoppard, 2000). Despite a growing body of critique engaging with the potential harm of the global movement more broadly (Campbell and Burgess, 2012; Mills and Fernando, 2014; Summerfield, 2012), very little of this has fed into a discussion of the specific problems that will be faced by local women in light of the expansion of Western psychiatric thought in the developing world via an era of ‘global mental health’. Does the intersection of global forces and local realities create new opportunities for women to challenge contexts that place their mental health at risk? Or is the expanding hand of psychiatric practice merely repeating the mistakes of old: a ­silencing of women’s voice and denial of women’s power to determine their own well-­being? This chapter engages with these concerns, through an exploration that attempts to 79 Jasmine Gideon - 9781784710859 Downloaded from Elgar Online at 11/03/2017 02:47:53AM via Sydney University

80  Handbook on gender and health locate the ‘voice’ of women within current global mental health discourses. It begins with  a brief review of psychiatry’s engagement with women. Then, it explores the discourse of the Movement for Global Mental Health (MGMH) through an examination of key texts about women’s mental health published since the start of the movement in 2007. Then, it presents the case history of a South African woman in mental health services encountered during fieldwork in 2010 and 2011 in ­KwaZulu-­Natal, South Africa. The case highlights the implications of a MGMH discourse for women’s lives. The chapter concludes by outlining the value of a mental health competency approach (Campbell and Burgess, 2012) in addressing women’s mental health in the Global South. The approach opens more actionable spaces where women can make  the  most  of  opportunities created by global–local partnerships for mental health and, most importantly, define their own routes to the achievement of mental well-­being.

MAD GIRLS, BAD GIRLS: THE PROBLEMATIC POSITIONING OF WOMEN IN PSYCHIATRIC DISCOURSE From the earliest days of psychiatric practice, the field has been associated with the regulation of women’s lives. Philippe Pinel, a forefather of psychiatry and inventor of ‘moral treatment’ (an approach emphasizing humanity, kindness and meaningful occupation, in the context of confinement) was an early contributor to establishing frameworks for services (Shorter, 1997). Appignanesi’s (2011) history of women and psychiatry describes the cases of a series of female patients under Pinel’s care. In these cases, recommendations often included marriage, highlighting the close relationship between psychiatric intervention and norms regarding women’s participation in society from the earliest days of the discipline. For example, ‘hysteria’ has been historically linked with psychiatry’s problematic engagement with women. The hysterical woman was one who was contrary to the ‘normal’ woman, displaying loud outbursts, lewd behaviour and heightened sexual appetites (Appignanesi, 2011). In Sigmund Freud’s initial theoretical accounts of hysteria, women’s madness was linked to early sexual experiences, positioning women’s sexual lives as a focal point for psychoanalysis. McOmber (1996) presents this as an early account of psychiatric silencing of women, embodied by Freud’s rejection of patients’ accusations of sexual assault by fathers when recounting early childhood experiences. Instead, Freud viewed such revelations as a form of resistance to therapy, rather than a valid truth. The elevation of practitioner truth as more valid than the patient’s truth remains an issue for mental health services today (Rose, 2008). The expansion of Freud’s theories into popular discourse during the twentieth century helped to solidify gender differences as an underlying feature of mental illness. Feminist Betty Friedan’s account of Freud’s elevation to social and cultural icon aptly sums up the movement of ideas in this period, where Freud’s ideas became an ‘an all embracing . . . ideology . . . theories [that] settled everywhere like fine volcanic ash’ (Friedan, cited in Appignanesi, 2011: 419). Hirshbein’s (2010) history of sex and gender in psychiatry notes how initial gendered perspectives of women were validated by psychiatry and informed general ideas of the day. For example, nineteenth-­century arguments espousing women’s

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Silencing women within ‘global mental health’ practice  ­81 emotional instability contributed to debates concerning women’s voting rights in the United States. The advent of the Diagnostic Statistical Manual of Disorders (DSM) in 1954 translated limited views of women into classification systems used by medical practitioners globally, establishing a discourse powerful enough to reify an ideal version of women around the globe (Ussher, 2010). Increased contributions from neurological and biological sciences helped to firmly establish psychiatry as a viable and trustworthy medical discipline. However, alongside these expansions, debates about gender role transitioned into debates of sex and biology, shifting focus from women’s emotional states to women’s bodies themselves as drivers of vulnerability to mental distress. For example, critical feminist scholar Janet Stoppard (2000) highlights that the medicalization of women’s lives quickly expanded in relation to processes of menstruation, pregnancy and childbirth, and menopause. These experiences are now linked to varying forms of depression, often accounted for by varying levels of reproductive hormones, particularly oestrogen (Leight and Fitelson, 2010; Ussher, 2010). A recent special issue of the International Review of Psychiatry on gender and mental health confirms the field’s ongoing interests in the aforementioned issues. With the exception of one article on culture and social constructions of gender (Andermann, 2010), the special issue was driven by epidemiological evidence arguing the biological foundations of women’s mental distress. Common mental disorders such as depression and anxiety (Keers and Aitchison, 2010; Parker and Brotchie, 2010), severe disorders such as bipolar disorder and schizophrenia (Abel et al., 2010; Diflorio and Jones, 2010; Smith, 2010), mental disorders in childbirth (Leight and Fitelson, 2010) and poor mental health outcomes for victims of violence (Howard et al., 2010) were presented as key areas of concern for the field. Debates highlighted the reliance of arguments about women’s lives and bodies on quantitative evidence. The accounts of thousands of women were presented using standardized questionnaires, surveys and screening tools in order to explain causes and experiences of mental disorders. The use of positivist and ‘objective’ methods to describe the lives of women can be linked to psychiatry’s ongoing efforts to justify its position as a true science (Foucault, 2008). This is crystallized in an increasing reliance on randomised control trials to support claims to expertise and increasing medicalization of the field (Bracken et al., 2012; Lafrance and McKenzie-­Mohr, 2013). The medicalization argument underpins many feminist critics who openly reject the ability of decontextualized quantitative evidence to buttress claims that mental conditions are firmly biological, and natural (Pilgrim and Bentall, 1999), or define the nature of women’s mental distress. Three broad framings can be used to organize feminist critiques of psychiatry. First, as alluded to above, scholars take issue with the methods used to engage with women during diagnostic procedures. Stoppard (2000) argues that positivist forms of the scientific method used to identify and name problems in women’s lives silence women’s experiences, diluting them to symptoms which align to diagnostic criteria. Dimensions of patients’ lives that do not feature on questionnaires are left out, and not considered as worthy of treatment. Second, medicalization links problems to individuals rather than environments, diverting attention from contexts that drive distress. By linking distress to faulty bodies or faulty cognitions, rather than locating those same bodies in relation to complex and

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82  Handbook on gender and health often distressing environments where they live, women must assume responsibility for the challenges they face (Burgess and Campbell, 2014; Kruger et al., 2014; Ussher, 2003). For example, whilst many interventions for post-­natal mental health problems remain focused on the body (Leiknes et al., 2013) it has been continually argued that periods of post-­ natal depression are understandable, particularly in environments with low social support (Husain et al., 2012; Wittkowski et al., 2014). This medicalization of women’s lives has been viewed as problematic, particularly if the result is an undermining of distress that occurs in response to social injustice (Kruger et al., 2014). Finally, critics focus on women’s ability to dictate the terms of their own treatment. Second-­wave feminists often viewed psychiatry as an agent of patriarchy, that restricted women’s voices through applications of therapy whenever they attempted to subvert ‘natural’ roles outlined in society (Millett, 1970). In non-­gendered contexts, mental health patients have been described as passive within treatment spaces (Speed, 2006). Patient engagement is further complicated by asymmetries in power between practitioners and patients of differing genders (Barnes et al., 2006; Burgess and Campbell, 2015). R.D. Laing (1960) was among the first psychiatrists who sought to overcome this asymmetry and its resulting silencing of patients. His work with schizophrenic patients highlighted the importance of engaging with the patient’s life world during treatment. His work drove further studies that argued the importance of viewing symptoms and responses through a patient’s subjective lens, which leads to a better quality of care and enables patients to contribute to their treatment (Barry et al., 2001; Mishler, 1984). Recent studies have argued for the importance of a holistic engagement with patients that, when driven by social constructivist and narrative approaches to medicine, allows for patient contributions to take centre stage (Robertson et al., 2005; Steslow, 2010; Ussher, 2003; Thomas and Bracken, 2004). These three categories of critique are united by a concern with outcomes that position women as the objects of the medical gaze, rather than as subjects and partners within services (Steslow, 2010). Debates on the nature of women’s distress highlighted above remain contentious, due to the positive contributions of biomedical framings of distress experienced by some individuals. In such cases, diagnostic criteria provide a sense of meaning and control to the lives of those affected by mental disorder (Foster, 2003). As such, this chapter does not reject outright the role of psychiatry in the lives of women. Rather, it seeks to draw attention to the workings of power within a psychiatric approach that, when utilized by well-­meaning groups of actors within the MGMH, may have dangerous implications for the lives of women in the Global South. The work of Foucault (2008) has effectively highlighted the ability of psychiatric discourse to position individuals in particular ways, and has laid the foundations for many critical scholars in the field of mental health. His arguments are a useful starting point for the evaluation of the current role of psychiatry in the lives of women in the Global South, where issues of power, discourse and voice are of the utmost importance (Farmer, 2004).

POWER, POSITION AND POSSIBILITIES FOR ACTION: A THEORETICAL FRAMEWORK FOR EXPLORING DISCOURSE Given that engagement in mental health services may disempower patients (Ingleby, 1981), it is important to develop a clear understanding of the impacts that treatment

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Silencing women within ‘global mental health’ practice  ­83 will have on the lives of women in the Global South who already experience widespread inequalities of power and participation (Cornwall, 2003). Speed’s (2006) examination of discourses among mental health patients in Ireland highlighted that an individual’s association to various discourses aligned them with a particular orientation to treatment and position in society. Individuals who aligned with a discourse of ‘I am a patient’ often used an illness signifier (diagnosis), were more likely to be less active within doctor–patient encounters, and accepted the boundaries set by the psychiatric framework. Conversely, individuals who aligned with a survivor discourse were likely to be more active, often rejecting the recommendations of psychiatry that did not fit with their own reality. This often included seeking out alternative options for support that better responded to their own voiced needs. Exploring the nature of the discourse around women within global mental health enables attention to the more complicated workings of power and agency, which are increasingly important within wider fields of international development (Madhok, 2013). As highlighted above by Speed (2006), discourses make certain actions possible through their power to make meaning and to shape existence within society, and to drive the lives and actions of individuals (Wetherell, 2001) and their relations to others (Harre and Moghaddam, 2003). For the purposes of this chapter, ‘discourse’ is defined in a Foucauldian sense as a group of statements that provide a way of representing objects or phenomena in society within the context of place and history (Hall, 2001), which sets an acceptable range of actions for individuals who are governed by the discourse. According to Hall (2001), analysis should aim to describe the six distinguishing features of a discourse in order to understand its operation. First, the analysis should identify statements about a concept that create knowledge and examples about what counts as the issue. Within psychiatry, this is often achieved through the use of diagnostic categories: collections of statements that mark symptoms and behaviours as a particular form of mental illness. The DSM and the International Classification of Disorders (Version 10) are the current ‘gold standard’ diagnostic and classification systems that establish knowledge and examples of mental ill-­health. Despite many advances in cross-­cultural psychiatry which sought to widen the scope of knowledge within the categories, the criteria continue to define disorders in relation to the body within Western frameworks of understanding distress (Bracken et al., 2012; Kirmayer, 2006; Summerfield, 2002). Second, the analysis should uncover rules that determine ways of talking about the topic; a collection of statements that, anchored to a particular historical context, govern what is thinkable about the issue. Within the global mental health field, the recently developed World Health Organization Mental Health Global Action Programme (mhGAP) has helped to redefine what is ‘thinkable’ about mental health in low-­and middle-­income countries. The new screening and treatment guidelines for low-­and middle-­income countries (WHO, 2010) are adapted from categories set out in the DSM and ICD-­10 guidelines, but leave room to explore social problems articulated by patients, in line with evidence that argues for the wider social determinants of mental ill-­health (Lund et al., 2011). Third, the discourse will create subjects who come to personify the discourse, thus defining an ideal type, and the object of attention for the discourse to govern. The fourth feature is the establishment of authority, which enables knowledge on the topic to acquire authority. In psychiatry, authority is inextricably linked to the production of scientific

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84  Handbook on gender and health evidence, and alliance with the biological sciences (Bracken et al., 2012). The MGMH is particularly concerned with the production of research in an effort to secure its authority to speak on behalf of the mentally ill in low-­and middle-­income countries. Entire special issues of journals have been devoted to this end: in 2011 a special issue of PLOS Medicine presented randomized control trials (RCTs) and cohort studies exploring the cost-­effectiveness of interventions for common mental disorders. There was a particular focus on highlighting contributions from clinical trials. A new book dedicated entirely to the production of trials for global mental health (Thornicroft and Patel, 2014) asserts the importance of randomized controlled trials as a route to addressing inequalities around mental health, which in this case relate to the higher levels of evidence emerging from high-­income countries compared to low-­income country settings, despite the higher levels of burden facing the latter. Fifth, the analysis of discourse should include practices for dealing with and managing subjects of the discourse. Within medical fields, these rules and practices revolve around treatment. Current recommendations within the MGHM framework articulate the importance of a blend between biomedical and psychological and psychosocial treatments, delivered at community level, particularly for individuals in low-­and middle-­ income settings (Hanlon et al., 2010; Patel et al., 2009; Thornicroft and Tansella, 2014). Whilst the inclusion of psychological therapies is undoubtedly a response to those arguing against the pharmaceuticalization of distress, recent studies highlight the inability of narrow psychological interventions to grapple with the complex social needs at the heart of women’s mental distress in low-­income settings (Burgess and Campbell, 2014; Petersen et al., 2012a; Summerfield, 2005). This suggests the need for new approaches to the management of mental distress for women in the Global South, particularly given the history of women’s reduced participation in their own lives both within mental health services (McKay, 2010; Ussher and Perz, 2010) and beyond (Madhok, 2013). Finally, the discourse should acknowledge that other discourses will arise with the power to regulate social practices in new ways. This is what enables a discourse to grow and change, maintaining its power throughout various historical moments. Within the MGMH, this is linked to calls for contributions from fields such as anthropology and other social sciences to contribute to understanding wider social determinants of mental distress (Campbell and Burgess, 2012). The remainder of this chapter will be dedicated to mapping the global mental health discourse’s engagement with women in the Global South, with a focus on the second and third dimensions articulated by Hall (2001). By exploring what positions women assume as subjects of the discourse, and what possibilities for action are enabled by the discourse, it is hoped that suggestions can be made to enable the MGMH to meaningfully respond to critiques facing psychiatry’s engagement with women. This is of utmost importance as the movement continues to establish the authority to identify what counts as valid experiences of, and responses to, mental and emotional distress for women globally. Methods A content analysis was used to map the approach of the global mental health discourse towards women. The aim of the analysis was to describe the nature of the discourse, in the hopes of answering the following questions:

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Silencing women within ‘global mental health’ practice  ­85 ● ●

How does the discourse present its main ‘subject’ (women)? What space does the discourse leave for women to contribute to addressing distress in ways that are linked to their own voices?

Six documents were included in the content analysis. The selection of documents was not intended to be systematic, but to establish the core ideas that establish the movement’s position towards women. As such, the documents were selected in light of their connection to the movement and their contributions to the growing field. The document at the heart of the analysis is a chapter from the recently published textbook Global Mental Health: Principles and Practice (Patel et al., 2014). Its stated purpose is to develop the ‘scientific foundations of global mental health and the practical methods for implementing and scaling up mental health programmes’ (Patel et al., 2014: xi) and it contains 20 chapters, each providing an overview of key interests and approaches in the field of global mental health. The selected chapter on women’s mental health (Fisher et al., 2014) provides a synthesis on the available evidence with an emphasis on practical implications for treatment. To deepen understanding of the ‘subject’ and practices for management set forth by the discourse, five highly cited articles published between 2007 (coinciding with the launch of the MGHM) and 2012 (the search parameters were 2007–2014) about women’s mental health in low-­income country settings were also reviewed (Table 5.1). These publications provide further examples of interventions, accounts of women’s voice (studies using qualitative methods), and establishment of the problem of ‘women’s mental health’. Table 5.1  Details about articles included in mapping of discourse Author and year of publication

Short title of paper

Number of citations (approx. av. per year), according to Google scholar citation index

Linked to the MGMH

Rahman et al.  (2008)

Cognitive behaviour therapy-­ based therapy delivered by community health workers for mothers with depression in Pakistan Stepped care for maternal mental health in South Africa Interventions for depression symptoms among adolescent survivors of war in Northern Uganda Prevalence and determinants of common perinatal mental disorders in women in low-­ and middle-­income countries: systematic review Explanatory models of depression among women in India

273 (45.5/year since 2008)

Author affiliation

31 (15.5/year since 2012)

Author affiliation Institutional affiliation

Honikman et al.  (2012) Bolton et al.  (2007) Fisher et al.  (2011)

Pereira et al.  (2007)

245 (35/year since 2007)

131 (43.7/year since 2011)

Author affiliations

66 (9/year since 2007)

Author affiliations

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86  Handbook on gender and health All are well-­cited publications, and linked to the movement through membership of the authors themselves or their institutional affiliations.2

THE CURRENT HISTORICAL MOMENT: WOMEN IN AN ERA OF GLOBAL MENTAL HEALTH The MGMH has effectively established itself as a champion of addressing global inequities in accessing mental health services (Patel and Prince, 2010). The wider discourse achieved its authority through association to traditional forms of psychiatric power: alliance with biomedical positioning of mental disorder, and a commitment to the production of evidence in the form of randomized controlled trials (Summerfield, 2012, 2008). In 2010, after only three years of action, the movement labelled itself as having ‘come of age’, and had effectively silenced critiques of its engagement in resource-­poor, non-­ Western settings vis-­à-­vis a body of epidemiological research that confirms a ‘burden’ of mental distress globally. This notwithstanding, ongoing critiques about the validity of the movement’s approach to intervention (Fernando, 2014; Mills, 2014; Mills and Fernando, 2014) prompts a review of how this new form of intervention will impact on women in the Global South. How Does the Discourse Present its Main ‘Subject’ (Women)? The Movement for Global Mental Health positions women in low-­and middle-­income countries (LMICs) as a vulnerable group in need of support, a position informed by acknowledgement of the wider social and structural determinants of mental distress. This understanding is derived largely from epidemiological studies, and when combined with evidence confirming the biological existence of mental illness, a multidimensional view of women’s distress begins to emerge. This establishes some complexity within the subject, which is aptly summarized at the outset of Fisher et al.’s chapter on women’s mental health: ‘From conception, the life experiences of girls and women differ from those of boys and men. Some of these pertain to intrinsic biological differences in female and male reproductive potential, but the more prominent differences are gender-­based and reflect disparities in opportunities’ (Fisher et al., 2014: 385). ‘Opportunities’ are linked to women’s experiences of wider social determinants of distress such as poverty, gender-­based violence and unpaid work. The inclusion of these social factors within arguments of causality is promising. However, developing a clear understanding of the subject is difficult, due to the absence of women’s voices within the evidence base defining the problem. Unlike historical accounts from early psychiatric practice which were drawn from rich case histories and stories of women’s lives (see Appignanesi, 2011), contemporary methods of research engagement informing the MGMH accounts of women are so reductionist that they produce an image of the ‘subject’ that shows not who women are, but rather what conditions they endure. Within the documents driving this analysis, women’s accounts emerge from epidemiological and other population-­level survey studies, whose aim is to validate the presence of the biological aspects of disorder. By relying on this form of evidence so heavily, the discourse obscures the wider meaning of distressing experiences to women, and reduces

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Silencing women within ‘global mental health’ practice  ­87 the field’s ability to understand the subject as a multidimensional actor. For example, in a discussion of women’s vaginal discharge as a trigger and symptom of mental health problems in India, Fisher et al. (2014) make use of the following evidence from a population study of 2494 women: 14% of women who reported vaginal discharge were more likely than the rest of the sample to report Common Mental Disorder (CMD) . . . incidence of this complaint in the follow up period was associated with CMD . . . and being younger, illiterate, of the religious minority and concerned about their husbands extramarital relationships . . . findings were interpreted as indicating that reported vaginal discharge could in this setting indicate somatization of psychological distress . . . a cultural idiom to explain fatigue and low mood, or a mechanism to avoid sexual intercourse or to legitimize professional help seeking. (Fisher et al., 2014: 402)

The above example highlights the ability of the discourse to silence the subject. Women provide a particular account of their lives that, even though a fixed measurement tool, highlights experiences of injustice and social challenges. However, the impact of these social realities is acknowledged through their association to diagnostic criteria for mental disorder. Marital discord and social isolation (linked to association within a minority social group) reported during the collection of survey data are not dynamics of women’s lives that are seen or heard by the discourse. Instead, focus shifts away from the problematic social and societal dimensions of women’s worlds, and onto the individual psychological dimensions, through linking social experiences to biology and somatic symptoms of depression. Furthermore, the potential power that women may access through using physiological symptoms as a form of resistance in their private lives (that is, using vaginal discharge as a mechanism to avoid sex with unfaithful partners) is erased by linking it to psychological distress. In this example, the subject has little space for action and emerges as silent and passive. In Fisher et al.’s (2011) systematic review of determinants of common perinatal mental disorders (CPMD) in LMICs, the simultaneous acknowledgement and dismissal of women’s voiced accounts provides another example of women’s position as silent ‘objects’ of psychiatric intervention, rather than as autonomous subjects. First, authors assert that the review ‘indicates that in these (low-­income) study settings women’s mental health is governed significantly by social factors . . . including many beyond individual control . . . and indicates that the prevalence of CPMD is highest among the most socially and economically disadvantaged women, especially those living in crowded households in rural areas’ (Fisher et al., 2011: 146). However, they later assert that women’s accounts presented in surveys to date were not sufficient, asserting the need to produce further ‘high-­quality evidence’ in order to clarify the lack of a ‘direct causal pathway’ (Fisher et al., 2011: 146) about causes of CPMD in women’s lives. In this case, the available evidence which speaks largely to the societal difficulties faced by women during childbirth and pregnancy in LMICs, rather than biology, is not seen as valid, confirming that a ‘direct causal pathway’ cannot be societally driven. Based on this analysis, the exact ‘subject’ of women is hard to describe. Acknowledgement of the impacts of social determinants of mental distress responds to critiques that position psychiatry as a field that ignores the political realities of the lives of women (Haaken, 2010). However, the absence of women’s actual voices within the evidence used to make claims on women’s behalf affirms the ongoing validity

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88  Handbook on gender and health of feminist critiques to current global mental health practices. Survey and questionnaire methods foreground socio-­demographic realities of women’s lives, but only so far; women’s lived experiences of these conditions are rarely presented. The result is a vacuum of knowledge about how women experience, cope with and survive conditions of poverty, violence and war. The discourse thus establishes a nameless, faceless ‘subject’, reduced to bodies existing in and often seen as disempowered by their experiences of complex social settings. The ‘silent’ subject illuminated above also highlights a process of divorcing political dimensions of women’s social distresses from the person, embodied within the reduction of societal complexities down to individual bodily symptoms and experiences. Despite a paucity of narrative accounts of women’s mental distress in low-­income country settings (Burgess and Campbell, 2014), the few qualitative studies conducted within the MGMH, as part of their acknowledgement of other ‘discourses’, also shift women’s accounts away from the socio-­political drivers of women’s distress and back towards the biological, in a similar vein to the survey data described above. In a qualitative study of 28 women’s narrative accounts of depression, Pereira et al. (2007) noted that women’s distress was often related to reproductive events. One woman’s account stated the following: ‘All my tensions started then only, when I started having only girls and when the third daughter was born, I was thinking what to do with all the girls? How will I manage?’ The above account also links distress to wider societal and structural norms, particularly the social value attributed to the birth of sons in India (Kishore and Spears, 2014; Sen, 2003). However, authors’ recommendations turn away from the social complexities of wider public life that form the backdrop to women’s accounts: findings of this research are that women who were identified as suffering from depressive disorder give expression through an array of somatic complaints, and locate their distress in the social disadvantages they experience in their daily lives, that the complaints often have cultural and symbolic significance, and that women often seek medical help, initially for their somatic complaints . . . Thus the most consistent and cross-­culturally valid feature of depressive disorders are the somatic symptoms . . . narratives we have elicited display that somatic complaints are central to the conceptualization of depressive disorders. (Pereria et al., 2007: 216–217)

Within such a process, authors effectively reinterpret their subjects through the voice of the expert. In doing so, the use of context-­rich methods with women by the MGMH does not achieve the desired hope of illuminating the subject, her experience of her world and how this establishes distress. Instead, individual bodies and minds experiencing psychological distress are reworked as the focal point. In light of these practices, what choices are available to women who want to tackle problematic worlds? What Space Does the Discourse Leave for Women to Contribute to Addressing Distress in Ways that are Linked to Their Own Voices? Fisher et al.’s (2014) chapter begins in a manner that appears to create a positive space for action towards the ‘more prominent’ (p. 385) social factors and fractured social realties that drive distress in women’s lives. However, the preceding analysis highlights that attending to social realities does not automatically translate to considering them as a point of interest for intervention.

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Silencing women within ‘global mental health’ practice  ­89 Discussions on interventions are typically divided into categories of promotion, ­ revention and treatment. The former two categories are most often linked to addressp ing the social drivers of distress in women’s lives. For example, promotion is discussed as follows: Promotion of the mental health of girls and women clearly requires cross-­sectoral approaches in which the protective factors of equality of participation in . . . education; access to income-­ generating occupations, safety from family and community violence . . . are secured in legislative and policy frameworks with clear mechanisms to ensure implementation. (Fisher et al., 2014: 406)

And under ‘prevention’, the authors state that: Structural interventions seek to modify contextual risk factors and thereby reduce the likelihood that mental health problems will occur . . . [Microfinance programmes] provide powerful evidence of the potential benefits for women of initiatives to reduce poverty and intimate-­partner violence and improve economic autonomy and promote gender equity at a local level. (Fisher et al., 2014: 406–407)

A cross-­sectional approach can be problematic for two reasons. First, it creates a division of labour that removes responsibility for tackling social determinants away from medical practitioners. Second, it draws the attention of medical practitioners further away from what women articulate as the issue of concern. Within such a system, approaches such as cash transfers, or local community social changes which have been linked to improved health outcomes (Vincent and Cull, 2012), are placed beyond the reach of mentally distressed women in treatment programmes who articulate the need for such forms of intervention within their accounts of distress. Furthermore, by positioning social issues as the object of ‘prevention’ activities, the agency that women exercise in seeking help from health services is blocked, as the more powerful service actors do not have any direct responsibility to address the non-­medical needs of clients beyond referral to social welfare sectors (Burgess, 2013; Laverack, 2012). Women’s responsibility and agency is instead measured through their ability to adhere to prescribed treatment programmes. For example, MGMH recommendations call for psychotherapy, cognitive behavioural therapy or pharmaceutical interventions for treating most common mental disorders. In the studies selected for this analysis, interventions utilized these recommendations and, in doing so, adapted them from Western standardized frameworks. For example, as part of a multilevel service programme for perinatal mental health in South Africa (Honikman et al., 2012), women received free one-­to-­one counselling from psychiatrists and counsellors, who could refer women to other social services as needed. However, only women who accepted counselling as an intervention were followed up by practitioners, and no data were provided on the outcomes of women who accessed social referrals, and the impacts of access to such services on women’s well-­being. This highlights the higher value of psychological interventions over those that fall outside the paradigm, in terms of the rejection of those outside the paradigm as valuable to addressing the problem of mental distress. In Pakistan, Rahman et al. (2008) implemented a cognitive behaviour therapy programme that focused on techniques such as active listening, and included collaboration with family members as a route to increasing local relevance of the intervention (Rahman, 2007). In both studies, women are not

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90  Handbook on gender and health given space to contribute to or choose the nature of their therapy; rejection of services is the only option. The above sections have outlined a discourse that approaches women as silent objects; bodies governed by a biomedical logic of engagement. This positioning translates into women having limited engagement in treatment design, and few opportunities to be heard, or participate in their treatment. The following section explores the real-­life impact of such a discourse on women in everyday settings, within South Africa.

DISCOURSES IN PRACTICE: A CASE EXAMPLE The South African mental health care service is anchored to global mental health recommendations, vis-­à-­vis its implementation of primary mental health care within a district health model of services. District hospitals offer emergency mental health services, and are supported at higher tiers of care in the delivery of care through partnerships with stakeholders across multiple sectors including social welfare and social work departments (Skeen and Kleintjes, 2010). Ethnographic research conducted in 2010 and 2011 as part of a study on rural South African women’s narratives of mental distress, community mental health services and the Movement for Global Mental Health (see Burgess, 2014; Burgess and Campbell, 2014) involved the collection of 14 case histories of women in formal mental health services. Women were treated by a cadre of staff who worked within the MGMH discourse. In a positive twist, many practitioners acknowledged the limits of this framework, and engaged with the realities of women’s lives. This resulted in attempts to work around the limitations of biomedical framing of women’s distress, using strategies to avoid a silencing of women’s voiced concerns, such as the establishment of local income generation activities for distressed women (see Burgess, 2014). Despite their best efforts, responses to women were limited by the wider discourse, resulting in a revolving door where women moved in and out of services due to lack of attention to the social issues framing distress. The following case exemplifies the women encountered during the ethnography. ‘P’3 (Box 5.1) embodies the myriad of social, relational and health-­driven complications shaping women’s lives in South Africa: management of HIV, limited financial resources, multiple familial responsibilities and exposure to sexual violence (Brandt, 2009). During the clinic observation, P stressed her social concerns, linking them to her suicidal ideation; a complex relationship between her HIV diagnosis and the inability to guarantee the well-­being of her children after her death, given that her alcoholic mother would be the only surviving next of kin. This case is useful as it highlights both the positive contributions made by an MGMH discourse, and its many limitations. Access to mental health services ensures support for the psychological dimensions of her case. Flashbacks and their resulting sleeplessness can have severe impacts on feelings of well-­being, and the overall sense of hopelessness that is linked to her suicidal ideation. This requires immediate attention, and is able to be addressed by a prescription of fluoxetine. However, the long-­term contributions of the fluoxetine intervention are limited, as it will only address the biological dimensions of her distress. The presence of socially engaged practitioners helps to ensure access to outlets for social support. However, the non-­governmental ­organization (NGO), social work and

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Silencing women within ‘global mental health’ practice  ­91 BOX 5.1  CASE HISTORY, PATIENT P FIELD NOTES, 15 NOVEMBER 2010 Patient, 1: female, 33 presenting issue: Suicidal ideation (plan to kill self and children) Social/Medical History HIV+ve, on ARV regime. Husband died in 2005, left with three children. Raped in 2007, one child from the rape incident. Patient History (Hx) Collected at Interview P is unemployed, only income is child support grant. P is also supporting her alcoholic mother who is never around the homestead, only stumbling home drunk at night. P has no additional social supports, but sometimes can talk to her sister but can’t depend on her very much as she lives too far away (5 rand each to get to her sister). P was brought in to the hospital by her social worker due to her suicidal ideation/planning/and danger to her children. P has been experiencing severe flash backs of rape incident – nightmares (once/week) that when they occur, she is unable to function, lead her to spend her time doing nothing, cannot complete daily tasks. Daily worries about children, how she will take care of them, who will take care of her children if she dies – her thoughts of suicide and killing her children are linked to her mother’s binge drinking episodes. Upon her arrival to hospital she was placed on fluoxetine for management, which she reports as helping her feel better. She has slept well since her arrival at the hospital, and no longer is thinking about suicide or harming her children. Treatment response Continued fluoxetine, referral to community NGO for social support and access to food parcels.

food parcels are temporary solutions at best. In light of recent South African research that highlights the strains facing these sectors more widely (Burgess, 2014; Dookie and Singh, 2012), knock-­on effects on the efficacy of cross-­sectoral partnerships to address women’s needs are likely.

DISCUSSION: ESTABLISHING SPACES FOR ‘REBEL’ WOMEN Despite the outwardly limiting discourses at the heart of the global mental health movement, there remains scope for improved engagements (Jackubec, 2004). First, the discourse presented in earlier sections highlights an acknowledgment of critiques, which leaves room for action in positive directions. As the body of empirical research supporting critical arguments about women’s mental distress in low-­income country settings expands, the need for the mainstream discourse to take on dimensions of that argument increases, in order for it to maintain its power (Foucault, 2008). This chapter highlights the dangers posed by current global mental health approaches to women in the Global South, through an analysis of the discourse driving the movement’s efforts. Findings indicate a very limited view of the ‘subject’, with women in LMIC settings silenced. This occurs through the methods of data collection and ana­ lysis, which establish a faceless subject named only by the socio-­demographic conditions that shape her environment, and the symptoms of disorder that shape her body. These two facets stand alone, with limited attention to their intersection and its outcome on a woman’s lived experience. The limited opportunities for the content of women’s accounts

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92  Handbook on gender and health to shape the view we have of the ‘subject’ created by qualitative and narrative research are reworked and filtered through a psychiatric framework. On such occasions, women’s lived experiences are reduced to examples of ‘culturally valid’ symptoms for mental disorder, rather than stand-­alone complex issues warranting intervention. Women are further silenced by the nature of treatment approaches used to respond to their distress. Treatment interventions focus on the individual, and in best cases, the social-­ relational dimensions of their worlds, rather than socio-­ structural issues that feature at the heart of women’s own accounts. As such, women’s engagement with their world is supported in one-­to-­one ways, in direct contradiction to the discourse acknowledgment of many social drivers of distress as being beyond any one individual’s control. Furthermore, women have very limited spaces to contribute to the shape of services, or engage in action on the issues they identify as problematic in their lives, as treatment approaches are narrowly defined prior to their exposure, often linked to interventions designed in high-­income country settings. This silencing of women within current MGMH frameworks can be linked to two wider frameworks: those for understanding the capacity and agency of ‘patients’, and frameworks for understanding the agency of women in the Global South more broadly. In contrast to earlier accounts of silencing in line with societal norms about women’s inferiority to men, silencing in this instance occurs through the distance of women’s accounts from existing evidence and expertise. As such, within the patient–practitioner dialogue, women’s accounts are overridden by the expertise of the practitioner, who seeks to provide help within their own framework of understanding of the problem. This position is enabled by enduring and often limited views of women’s agency, and the agency of mentally distressed individuals. Within wider development discourse, women’s agency has been problematically viewed as valid only in instances where it is in line with a neoliberal logic: discrete visible acts that reject social norms viewed as problematic by global, high-­income partners (Madhok, 2013). Alternatively, further arguments seek to highlight the agency visible in the absence of action, or ‘small wins’, as they may be more accurate indications of how women are able to act within the realities of their current social environments (Madhok, 2013; Mannell, 2014). When applied to the sphere of global mental health, neoliberal logic frames women as empowered agents only when they engage in a project of improving their mental health through adherence to the services provided. This idea is supported by the movement’s emphasis on secondary prevention that promotes increased knowledge and training for local women about mental health issues within the Western framework of mental distress (Petersen et al., 2012b). However, given the narrow conceptualizations of mental distress embodied by existing treatments, it may be more interesting to understand and explore refusals and defaults on treatments, as sites of agency. These stories of rejection may tell us about the local relevance of services. For example, recent studies highlight the actions of women who work outside of MGMH interventions to develop their own more relevant responses, such as women who start saving groups with members of their treatment support groups (Petersen et al., 2012a). Response to the problems of power and agency highlighted within this chapter could be addressed through an alternative approach to the design of services for women in low-­income settings. A community mental health competency approach (Burgess, 2012; Campbell and Burgess, 2012) has been argued as one route to ensure that communities,

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Silencing women within ‘global mental health’ practice  ­93 Table 5.2  Community mental health competencies Competency

Description

Knowledge

Enhancing the ability of communities to identify and refer serious cases of mental ill-­health and respond to others in a culturally appropriate manner; supporting the acceptance of cultural and social narratives among professionals. Helping communities to develop or expand on existing skills that can contribute towards addressing mental ill-­health. As part of this process, communities should also develop better understandings of the links between social environments and mental health outcomes (critical consciousness). Promoting ‘successful’ dialogue between outsider mental health professionals, local mental health service sectors and within target communities about challenging issues. Supporting community desire and ability to exercise agency to improve the conditions that they feel impact upon their mental health by supporting connections to material and symbolic resources where appropriate.

Recognition of individual and group-­based skills, and solidarity to tackle the issue Safe social spaces and dialogue Partnerships for action

Sources:  Burgess (2012), Campbell and Burgess (2012).

and in particular women (Burgess and Campbell, 2014), remain in the driving seat of their treatment. The competencies summarized in Table 5.2 emerged through research into community mental health services in South Africa (Burgess, 2012; Campbell and Burgess, 2012). Each principle was identified as a key psychosocial resource linked to the development of spaces where mental health can be addressed in locally sensitive and relevant ways. The crux is a participatory framework driven by true dialogue (Habbermas, 1984) between service providers, mental health researchers and communities, working collaboratively to bring preventative and treatment approaches more in line with each other. Campbell and Burgess (2012) argue for the important contributions of the Movement for Global Mental Health in this vein, stating that through global partnerships, local communities have potential opportunities to build, expand and leverage existing resources in ways that can tangibly improve their lives. As such, a reformulation of the approach taken to engagement with local women would seek to position them as equal contributors and collaborators to treatment spaces, rather than passive actors or handmaidens to the movement through roles as health volunteers (Burgess, 2012; Campbell and Burgess, 2012), while making the most of the power presented by the global movement and its discourse. Furthermore, community mental health competencies demand the use of varied methods in order to develop a wide range of local understandings of issues such as knowledge and existing resources within a community. For example, the use of narrative research to highlight women’s own accounts and positioning of distress within their own worlds would highlight a series of social factors local to the community, and what existing coping strategies women already use in order to tackle distress that can become the foundation of interventions to support them. The work of more powerful actors would

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94  Handbook on gender and health then be to engage with these existing successes as a starting point for treatment. In this vein, women are seen as capable actors with valuable local knowledge about their own experiences, and mental health treatment support groups delivering evidenced-­based psychological treatments emerge as locations to anchor social development initiatives such as income-­generating activities or skills training, to create opportunities to mitigate wider social problems that impact on women’s experiences of mental distress (Burgess, 2013). A reconfiguration of this style views action around women’s mental health as meaningful when women are positioned as the subjects of interventions, rather than the object on which a discourse acts. A community mental health competency approach provides opportunities for individuals and communities to promote and respond to their own causal models of distress in ways that challenge the social and economic hardships that reside at the core of their distress, alongside attention to the delivery of mental health services that focus on the body. Furthermore, key psychosocial resources such as knowledge, solidarity and critical consciousness are also linked to the foundations for communities to engage in acts of struggle that challenge and ultimately transform the unequal social relations that frame mental distress (Freire, 1973). By viewing mental health services as the location for such opportunities, it may be possible that the movement for global mental health can shift its discourse away from the silencing of women’s voices and, often, accounts of fractured social worlds, into a discourse that promotes action that directly responds to these concerns in small but meaningful ways for women’s everyday survival.

NOTES 1. See www.globalmentalhealth.org. 2. Membership details are available as public information on the movement’s website. 3. Patients’ names have been replaced with initial psuedonyms to protect anonymity.

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96  Handbook on gender and health Howard, L.M., Trevillion, K. and Agnew-­Davies, R. (2010). Domestic violence and mental health. International Review of Psychiatry, 22(5), 525–534. Husain, N., Cruickshank, K., Husain, M., Khan, S., Tomenson, B. and Rahman, A. (2012). Social stress and depression during pregnancy and in the postnatal period in British Pakistani mothers: a cohort study. Journal of Affective Disorders, 140(3), 268–276. Ingleby, D. (1981). Critical Psychiatry: The Politics of Mental Health. Harmondsworth: Penguin. Jakubec, S. (2004). The ‘world mental health’ framework: dominant discourses in mental health and international development. Canadian Journal of Community Mental Health, 23(2), 23–38. Kadri, N. and Alami, K.M. (2009). Depression and anxiety among women. In: Chandra, P.S., Herrman, H., Fisher, J., Kastrup, M., Niaz, U., Rondón, M.B. and Okasha, A. (eds), Contemporary Topics in Women’s Mental Health: Global Perspectives. 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The Divided Self: An Existential Study in Sanity and Madness. London: Penguin Adult. Laverack, G. (2012). Where are the champions of global health promotion?. Global Health Promotion, 19(2), 63–65. Leight, K. and Fitelson, E. (2010). Childbirth and mental disorders. . . . International Review of Psychiatry, 22(5), 453–471. Leiknes, K., Cooke, M., Jarosch-­von Schweder, L., Harboe, I. and Høie, B. (2013). Electroconvulsive therapy during pregnancy: a systematic review of case studies. Archives of Women’s Mental Health, 18(1), 1–39. Lund, C., De Silva, M., Plagerson, S., Cooper, S., Chisholm, D., Das, J., . . . Patel, V. (2011). Poverty and mental disorders: breaking the cycle in low-­income and middle-­income countries. Lancet, 378(9801), 1502–1514. doi:10.1016/S0140-­6736(11)60754-­X. Madhok, S. (2013). Rethinking Agency: Developmentalism, Gender and Rights. New Delhi: Routledge. Mannell, J. (2014). Adopting, manipulating, transforming: tactics used by gender practitioners in South African NGOs to translate international gender policies into local practice. Health and Place, 30, 4–12. McKay, E.A. (2010). ‘Rip that book up, I’ve changed’: unveiling the experiences of women living with and surviving enduring mental illness. British Journal of Occupational Therapy, 73(3), 96–105. McOmber, J.B. (1996). Silencing the patient: Freud, sexual abuse and the etiology of hysteria. Quarterly Journal of Speech, 82, 343–363. Millett, K. (1970). Sexual Politics. New York: Doubleday. Mills, C. (2014). Decolonizing Global Mental Health: The Psychiatrization of the Majority World. Chichester: Routledge. Mills, C. and Fernando, S. (2014). Globalising mental health or pathologising the Global South? Mapping the ethics, theory and practice of global mental health. Disability and the Global South, 1(2), 188–202. Mishler, E. (1984). The Discourse of Medicine: Dialectics of Medical Interviews. Norwood, NJ: Ablex Publishing. Parker, G. and Brotchie, H. (2010). Gender differences in depression. International Review of Psychiatry, 22(5), 429–436. Patel, V., Goel, D.S. and Desai, R. (2009). Scaling up services for mental and neurological disorders in low-­ resource settings. International Health, 1(1), 37–44. doi:10.1016/j.inhe.2009.02.002. Patel, V., Minas, H., Cohen, A. and Prince, M.J. (eds) (2014). Global Mental Health: Principles and Practice. Oxford: Oxford University Press. Patel, V. and Prince, M. (2010). Global mental health: a new global health field comes of age. JAMA: Journal of the American Medical Association, 303(19), 1976–1977. Pereira, B., Andrew, G., Pednekar, S., Pai, R., Pelto, P. and Patel, V. (2007). The explanatory models of depression in low income countries: Listening to women in India. Journal of Affective Disorders, 102(1–3), 209–218. Petersen, I., Baillie, K. and Bhana, A. (2012a). Understanding the benefits and challenges of community engagement in the development of community mental health services for common mental disorders: lessons from a case study in a rural South African subdistrict site. Transcultural Psychiatry, 49, 418–437. Petersen, I., Bhana, A. and Swartz, L. (2012b). Mental health promotion and the prevention of mental dis­ orders in South Africa. African Journal of Psychiatry, 15(6), 411–416.

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Silencing women within ‘global mental health’ practice  ­97 Pilgrim, D. and Bentall, R. (1999). The medicalisation of misery: a critical realist analysis of the concept of depression. Journal of Mental Health, 8(3), 261–274. Rahman, A. (2007). Challenges and opportunities in developing a psychological intervention for perinatal depression in rural Pakistan – a multi-­method study. Archives of Women’s Mental Health, 10(5), 211–219. Rahman, A., Malik, A., Sikander, S., Roberts, C. and Creed, F. (2008). Cognitive behaviour therapy-­based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-­randomised controlled trial. Lancet, 372(9642), 902–909. Robertson, A., Venter, C. and Botha, K. (2005). Narratives of depression. South African Journal of Psychology, 35, 331–345. Rose, D. (2008). Madness strikes back. Journal of Community and Applied Social Psychology, 18, 638–644. Saxena, S., Thornicroft, G., Knapp, M. and Whiteford, H. (2007). Resources for mental health: scarcity, inequity, and inefficiency. Lancet, 370(9590), 878–889. doi:10.1016/S0140-­6736(07)61239-­2. Sen, A. (2003). Missing women revisited: reduction in female mortality has been counterbalanced by sex selective abortions. British Medical Journal, 327, 1297–1298. Shorter, E. (1997). A History of Psychiatry. Toronto: John Wiley & Sons. Skeen, S. and Kleintjes, S. (2010). ‘Mental health is everybody’s business’: roles for an intersectoral approach in South Africa. International Review of Psychiatry, 22(6), 611–623. Smith, S. (2010). Gender differences in antipsychotic prescribing. International Review of Psychiatry, 22(5), 472–484. Speed, E. (2006). Patients, consumers and survivors: a case study of mental health service user discourses. Social Science and Medicine (1982), 62(1), 28–38. doi:10.1016/j.socscimed.2005.05.025. Steslow, K. (2010). Metaphors in our mouths: the silencing of the psychiatric patient. Hastings Center Report. http://onlinelibrary.wiley.com/doi/10.1353/hcr.0.0279/full. Stoppard, J. (2000). Understanding Depression: Feminist Social Constructionist Approaches. London: Routledge. Summerfield, D. (2002). ICD and DSM are contemporary cultural documents. BMJ: British Medical Journal, 336(7651), 324. doi:10.1136/bmj.324.7342.914/b. Summerfield, D. (2005). ‘My whole body is sick . . . My life is not good’: a Rwandan asylum seeker attends a psychiatric clinic in London. In: Ingleby, D. (ed.), Forced Migration and Mental Health: Rethinking the Care of Refugees and Displaced Persons. New York: Springer Publishing, pp. 97–114. doi:10.1007/0-­387-­22693-­1_6. Summerfield, D. (2008). How scientifically valid is the knowledge base of global mental health?. BMJ: British Medical Journal, 992–994. http://search.ebscohost.com/login.aspx?direct=trueanddb=hchandAN=3200570 5andsite=ehost-­live. Summerfield, D. (2012). Afterword: Against ‘global mental health’. Transcultural Psychiatry, 49(3–4), 519–530. Thomas, P. and Bracken, P. (2004). Critical psychiatry in practice. Advances in Psychiatric Treatment, 10(5), 361–370. Thornicroft, G. and Patel, V. (2014). The importance of trials for global mental health. In: Thornicroft, G. and Patel, V. (eds), Global Mental Health Trials, 1st edn. Oxford: Oxford University Press, pp. 3–17. Thornicroft, G. and Tansella, M. (2014). Community mental health care in the future. Journal of Nervous and Mental Disease, 202(6), 507–512. Ussher, J. (2003). The ongoing silencing of women in families: an analysis and rethinking of premenstrual ­syndrome and therapy. Journal of Family Therapy, 25(4), 388–405. Ussher, J. (2010). Are we medicalizing women’s misery? A critical review of women’s higher rates of reported depression. Feminism and Psychology, 20(1), 9–35. Ussher, J. and Perz, J. (2010). Disruption of the silenced-­self: the case of pre-­menstrual syndrome. In: Jack, D.C. and Ali, A. (eds), Silencing the Self across Cultures: Depression and Gender in the Social World. Oxford: Oxford University Press, pp. 435–458. Vincent, K. and Cull, T. (2012). Impacts of social cash transfers: case studies across southern Africa. IESE Publications, Somalia Cash Consortium. Wetherell, M. (2001). Themes in discourse research: the case of Diana. In: Wetherell, M., Taylor, S. and Yates, S.J. (eds), Discourse Theory and Practice: A Reader. London: Sage, pp. 14–28. Wittkowski, A., Gardner, P.L., Bunton, P. and Edge, D. (2014). Culturally determined risk factors for postnatal depression in Sub-­Saharan Africa: a mixed method systematic review. Journal of Affective Disorders, 163, 115–124. doi:10.1016/j.jad.2013.12.028. World Health Organization (WHO) (2010). mhGAP intervention guide for mental, neurological and substance use disorders in non-­specialized health settings: mental health Gap Action Programme (mhGAP). Geneva: World Health Organization. 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6.  Cost-cutting, co-production and cash transfers: neoliberal policy, health and gender Deborah Johnston

INTRODUCTION The gendered impact of health sector reform has been an important topic for research, uncovering the uneven impact on women and men, both as users of health services and health sector workers. However, when looking at neoliberal policy overall, it is important to consider the general health impacts of neoliberal economic and social protection policy. This chapter has two aims. First, it will argue that changes in economic and social protection policy compound changes in health policy, that is, that it is useful to establish a wider framework to understand the relationship between neoliberal policy, gender and health. Second, it will highlight the increasing health role of neoliberal social protection policy, in the form of cash transfer interventions. Cash transfers have become the stock of social protection policy in both low-­and middle-­income countries. Whilst cash transfers might have a wide array of non-­health aims, they often have direct and indirect health impacts. Indeed, some are increasingly designed by libertarian paternalists, who intend to use cash incentives to directly change people’s health choices. In this sense health-­related libertarian paternalism in low-­and middle-­income countries can be quite different from the experiments in high-­income countries, where health interventions take the form of subtle ‘nudges’ to the ­environment1 or small targeted cash incentives to deal with deeply ingrained health problems (for example, drug addiction and alcohol abuse) among ‘hard to treat’ patient groups (for example, those with chaotic lifestyles or the homeless) (Medlin and de Walque, 2008). In contrast in low-­and middle-­income countries, libertarian paternalism has a broader role for cash incentives, as a key means for promoting the uptake of health services, ­medication or behaviour change. The evidence is that these incentives have mixed impacts. However, this chapter will argue that it is more important to recognize that they ‘blame’ the individual for illness, thereby ignoring the way in which illness may be produced by socio-­economic structures and overlooking the role of health systems in failing to prevent or respond to poor health. Finally, the targeting of female care-­givers by many conditional cash transfer schemes has, arguably, reinforced disadvantageous gender stereotypes. Definitions of neoliberalism encounter the problem that its forms vary from context to context (Cornwall et al., 2008; Saad-­Filho and Johnston, 2005: 2–3; Willis and Khan, 2009). However the most basic feature of neoliberalism is the systematic use of state power to impose financial market imperatives in a domestic process that is replicated internationally by ‘globalization’. At its heart neoliberalism is a particular organization of capitalism that has evolved to protect capital and to reduce the power of labour. This is achieved by means of social, economic and political transformations imposed by internal 98 Jasmine Gideon - 9781784710859 Downloaded from Elgar Online at 11/03/2017 02:47:53AM via Sydney University

Neoliberal policy, health and gender  ­99 forces as well as external pressure from donors and international institutions including the World Bank and the International Monetary Fund (IMF). Neoliberal policy commonly consists of various fundamental features: increased global economic integration, reduced government regulation, contractionary fiscal and monetary policy, reduction in social rights and benefits, and curtailing of union powers (Saad-­Filho and Johnston, 2005: 2–4). This chapter will first briefly discuss neoliberal health sector reforms, before setting out the link between economic policy and health, raising the issue of widening gendered inequalities under neoliberalism. Here, following other writers, a ‘gender lens’ is constructed around gender as an ‘organising principle of social life’ (Mackintosh and Tibandebage, 2006). Finally, the chapter will turn to the issue of neoliberal social ­protection policy and the role played by cash incentives.

NEOLIBERAL HEALTH SECTOR REFORMS AND GENDER: THE NEED FOR CONTEXT Investing in Health: Neoliberal health policy is most clearly exemplified by the World Bank’s World Development Report (1993). The report suggests a threefold approach to improving health in poor countries: economic growth through liberalization; the prioritization of government spending on the most cost-­effective health programmes; and the promotion of greater competition in the delivery of health services. The debate over the gendered effects of neoliberal health policies has been a complex one. On the one hand, neoliberal reforms have usually cut the real size of health budgets, introduced privatization and user fees, and led to a deterioration in the remuneration of health sector staff (Willis and Khan, 2009). On the other hand, neoliberal health theory has focused on the co-­production of health, sought to improve the sustainability of health services, and has also coincided with the mainstreaming of gender in health services and the setting of Millennium Development Goals with explicitly gendered targets (Willis and Khan, 2009; Payne and Doyal, 2010). Unpicking the gendered health outcomes requires some consideration of how each of these processes has interacted with the economic and social structures in place in particular settings. Certainly the literature highlighting the negative impacts of health sector reform on health outcomes and on worker morale is substantial. At the macro level the tendency for neoliberal health reforms to be associated with a shift of government expenditure away from health has been identified. Cutler et al. (2006: 110) report studies that suggest that China’s health progress stagnated due to the change in the allocation of public resources towards high-­growth sectors. Indeed, Cutler et al. (2006: 110) argue that for the two largest countries, India and China, ‘there is a negative correlation between decadal rates of economic growth and progress in reducing infant and child mortality’. This conclusion is born out of evidence that almost all of China’s notable reduction in infant mortality happened prior to the acceleration in growth, while in India the apparent acceleration of growth from the early 1990s was accompanied by a slowdown in the reduction in infant mortality. Overall, Stuckler and Basu (2009) argue that IMF-­sponsored reforms can clearly be seen to have been associated with a wide range of negative health outcomes: weakened health care systems, reduced effectiveness of health-­focused development aid, and

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100  Handbook on gender and health impeded efforts to control tobacco, infectious diseases, and child and maternal mortality. They argue that this is because strict conditionality often translates into lower spending on public health and health care delivery. Dennis and Zuckerman (2008: 296) generally observe that health expenditures are limited by the high level of debt servicing that poor countries are obliged to make; and Rowden (2008) makes an explicit link between the levels of health expenditure and IMF-­imposed expenditure targets. Rowden and Thapliyal (2007) present the findings of a quasi-­independent evaluation of the IMF, which found that only US$3 in every US$10 of annual aid increases are spent, with the remainder being used to build up international reserves or draw down debt. Noting the limited evidence, reviews of the gendered impact of health sector reform such as Mackintosh and Tibandebage (2006) or Willis and Khan (2009) conclude that women have been disproportionately affected by the introduction of user charges and are the main providers of unpaid labour in community-­based care. Specifically looking at maternal mortality, Pandolfelli et al. (2014) analyse data from 37 African countries to understand the impact of IMF and World Bank reform loans. Looking at the period 1990 to 2005, they conclude that the statistical evidence strongly suggests that receipt of a structural adjustment loan adversely affects maternal mortality. Parsitau (2008) argues that structural adjustment in Kenya adversely affected women’s health, focusing particularly on outcomes related to reproductive health and maternal mortality; while Gideon (2008) argues that the privatization of health care provision as part of neoliberal reforms in Chile worsened gender inequalities in accessing health services, and for many women increased the burden of unpaid care. Aside from the impacts of general deficit controls, specific ceilings on the public sector wage bill have prevented both the employment of additional health workers, as well as wage increases to retain existing workers. Although the IMF issued a statement in 2007 that it would only operate wage ceilings where necessary, Rowden (2008: 20) argues that flexibility on ceilings has been ‘the exception and not the rule’. Wage ceiling restrictions imposed by the IMF are particularly damaging given that the public sector in many poor countries has been chronically underfunded for some time, with few donors paying recurrent salary costs (Rowden, 2008: 20–21). Following economic reform in Mozambique and in rural Bangladesh, Noormahomed and Segall (1994) and Standing et al. (2008), respectively, argue that basic health expenditure worsened, while the quality of services and the morale of health workers declined. The impact of worsening employment conditions for health sector workers was particularly bad for female health workers due to the gendered nature of staffing hierarchies and policy-­setting (Mackintosh and Tibandebage, 2006). Underlying neoliberal health policy has been a change to the concept of health rights and roles. A positive reading of this might emphasize the insights produced by the neoliberal focus on co-­production of health services, which concentrates on the way that the health care system is jointly produced by heath care institutions and communities (Ostrom, 1996). Some authors have argued that using a co-­production framework of analysis is essential to understand the complex operation of primary health care systems and in policy options (Abimbola et al., 2014). However, underlying the concept of co-­ production is a new vision of health care rights and responsibilities. At issue is the conceptualization of health rights, where earlier conceptions of state-­provided health rights have been negated in favour of an approach that sees health care as a service delivered by both the state and the private sector (Evans, 2002; Gideon, 2008). The privatization

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Neoliberal policy, health and gender  ­101 of health care services has generally led to many activities being transferred back into the household (Gideon, 2008), and Mackintosh and Tibandebage (2006) argue that the concept of co-­production ignores the extent to which such activities are reliant on low-­ income women’s unpaid work. Cornwall et al. (2008) critically review the way that gender has been mainstreamed generally, while Freedman (2005), Zia (2009) and Standing (2007) debate the issue for health specifically. There is agreement that the privatization of health care and the particular way that gender has been mainstreamed mean that the debate has been depoliticized, with concepts such as agency and empowerment given a conservative makeover (Cornwall et al., 2008). The neoliberal approach, despite its gender mainstreaming, fails to take account of the social and political factors which facilitate women’s disadvantage in health access and outcomes (Fine and Rose, 2001; Sen and Mukherjee, 2014). As such, two elements from the earlier discussion should be emphasized. First, the role of the state in the provision of health care has been reduced and rights to health have been stripped back. Second, neoliberal reform meant that health access became more sensitive to income and increased the necessity of unpaid care activities. Thus, to understand the gendered outcomes of health reform we need to understand how neoliberal economic reforms have had gendered impacts on income and time burdens.

NEOLIBERAL GROWTH PATHS, GENDER AND HEALTH Investing in Health: In this section, a schematic relationship will be developed to link neoliberal growth paths with gender and health. Interestingly neoliberal thought itself suggests a clear link between economic growth and health status, with growth leading to health improvement. The policy view that ‘wealthier is healthier’ is most clearly exemplified by the World Bank’s World Development Report (1993). The report suggests a threefold approach to improving health in poor countries: economic growth through liberalization; the prioritization of government spending on the most cost-­effective health programmes; and the promotion of greater competition in the delivery of health services. The advocates of ‘growth first’ often refer to the statistical patterns found in cross-­ country analysis. Updating the earlier Preston curve, Pritchett and Summers (1996) argue that data from 1960 to 1985 for a large number of countries clearly shows that increases (decreases) in gross domestic product (GDP) per capita improve (worsen) infant and child mortality. This kind of statistical evidence has been paired with historical analysis of the mortality decline that took place in the now rich countries in the eighteenth and nineteenth centuries. Many have argued that improved nutrition was key in raising life expectancy in eighteenth-­and nineteenth-­century Europe (for a review, see Cutler et al., 2006: 100–101). This evidence, both historical and contemporary, has been used to endorse ‘policies that downplay the role of any deliberate public action in health ­improvement’ (Cutler et al., 2006: 110). If countries are growing it is assumed that the health of their inhabitants will automatically improve. This view of the historical and contemporary evidence, however, has been challenged. First, there have been a number of reassessments of the historical record that downgrade the role of nutrition improvements and point instead to the importance of the public health environment (Cutler et al., 2006; Leys, 2010). At the same time, complexities in the

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102  Handbook on gender and health contemporary experience have been highlighted. Marmot (2005: 1102) and Cutler et al. (2006: 114) have both reminded us of the lack of correlation between levels of national income and life expectancy among the now rich countries. There are also numerous examples of poor countries where health outcomes appear good, and sometimes better than the now rich countries. Marmot (2005: 1102) reminds us that Costa Rica and Cuba stand out as countries with gross national products (GNPs) less than $10 000, and yet have life expectancies of 77.9 years and 76.5 years, respectively; health outcomes that are no worse and perhaps better than those of the US, with a per capita income 20 times larger (Leys, 2010: 1). Indeed, in the original Pritchett and Summers (1996) article no discernible link between wealth and life expectancy could be found. In his study of the data, Kenny (2005) finds that there has been a significant convergence in non-­income welfare (including life expectancy) across the world, while income has not converged. Kenny concludes that ‘[g]iven that there has not been convergence in the standard income indicator, this may suggest that income is only one among a number of factors in determining quality of life outcomes’ (Kenny, 2005: 10). Hanmer et al. (2003) use data on infant and child mortality from 115 countries over the period 1960 to 1994 to re-­estimate the relationship found by Pritchett and Summers (above). They find that while per capita income is important, so too are indicators of health service availability, education and gender inequality. They argue that this shows that income alone is not the key driver of health, and that much can be achieved by governmental policy. In the absence of a clear relationship between growth and health, many studies have focused on inequality as a mediating factor. Certainly growth in the neoliberal era is inherently uneven in character and worsens income inequality (for a review, see Cornia, 2004; Berik et al., 2009). Durevall and Lindskog (2009) pick out three ways in which income inequality impacts on health, which can be summarized as the absolute income effect, the public goods effect and the relative income effect. First, high inequality in poor countries implies that many live with a low absolute income level, suggesting high rates of poverty. The second mechanism is also one that chimes with other stories: that highly unequal societies will have a lower provision of public health provision. The third mechanism set out by Durevall and Lindskog is perhaps the most innovative and challenging of the income inequality literature: that income inequality is an indicator of social distance between individuals, and the larger the distance, the greater the psychosocial stress suffered by the population as a whole, leading to worsening national health (Durevall and Lindskog, 2009). Accordingly, if a growth period was to raise everyone’s incomes in an uneven fashion, thereby increasing income inequality, overall health would be reduced, even if everybody is better off in absolute terms. Social cohesion, it is argued, will have worsened, which will lead to greater stress and violence. Within the academic literature there is little agreement on each of these mechanisms (Durevall and Lindskog, 2009). While authors like Wilkinson and Pickett (2010), in their widely acclaimed book The Spirit Level, suggest that the evidence is clearly there for the relative income hypothesis and the public goods story, others argue that there is no direct link from income inequality to health. For example, Deaton (2003) argues that absolute income remains important, but not income inequality per se. Deaton cites a wide range of empirical evidence, both looking at cross-­country comparisons and also considering changes over time in any one country. Other authors also suggest that the income inequality story is fragile (Leigh et al., 2009), or that it proxies for other factors such as

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Neoliberal policy, health and gender  ­103 polarization (Pérez and Ramos, 2010) or a lack of social capital or appropriate institutions (Knowles and Owen, 2010). Seeing health in an undifferentiated way is also mistaken. Rather than broad-­brush stories, Fine (2009) suggests that we need to better understand the health conditions faced by various segments of the population (for example, malaria, diabetes, heart disease), how they are generated within society, and the nature of health service provision, both public and private. If the relationship between wider social and economic factors and individual health is highly contingent, how then can we conceptualize it in a way that is analytically valid? Political economy work on health seeks to explain how poor health or affliction (as O’Laughlin, 2013 terms it) is produced, often unintentionally, by the nature of production structures and the social and political factors that determine health care provision. As part of this, the various patterns of production in any one economy will affect the nature of employment and self-­employment, the income received, other workplace benefits and the location of work; all of which will affect health by determining the physical and mental demands of work, migration status and the ability to make claims on both private and public health systems. As O’Laughlin (2013) reminds us, affliction is as much about the conditions of labour as it is about health provisioning. Using a production of affliction approach there are specific reasons to be concerned about the pattern of growth under neoliberal policy. While neoliberal policy is diverse in its material content in various settings, it commonly consists of various fundamental features: increased global economic integration, reduced government regulation, contractionary fiscal and monetary policy, reduction in social rights and benefits, and curtailing of union powers (Saad-­Filho and Johnston, 2005). Berik et al. (2009) summarize evidence that neoliberal policy reforms have increased income inequalities by gender, race and class. To understand gendered health impacts, we need to unpick the specific character of neoliberal policy in terms of the combined impact on incomes, time constraints and labour benefits (such as sick leave and employer-­provided health services) for particular groups of women and men. As Berik et al. (2009) note, it is hard to draw simple conclusions about the impact of neoliberal reform on women’s employment. In some countries, women have greater employment opportunities, whilst in other countries diverse patterns of industrial collapse and industrial upgrading have led to a collapse in formal sector employment opportunities (Berik et al., 2009; Kucera and Tejani, 2014). However, even where formal sector employment was feminized, there was often an accompanying trend towards poor employment conditions introduced as neoliberal labour market policy sought to increase flexibility and reduce costs for employers (Cornwall et al., 2008; Berik et al., 2009; Standing, 1999). Berik et al. (2009) point to trends in some settings for increasing use of home-­based workers, who are predominantly women with no formal sector options and/ or who lack childcare to allow them to work outside the house. Home-­based workers typically work for lower pay, on disadvantageous terms (such as piece rate), are usually not covered by labour legislation and work long hours. While we should not overlook the empowering nature of increased female employment (Kabeer, 2008), the weakening of labour rights and the casualization of jobs impacted on health care access in very particular ways for female workers, given this greater predomin­ ance of women workers in casualized and informal sectors (Razavi, 2007). The weakening of employment standards has meant that in general employers are increasingly able

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104  Handbook on gender and health to externalize responsibility for the health of workers (O’Laughlin, 2013; Hickel, 2012). Mackintosh and Tibandebage (2006) and Razavi (2007) both conclude that women are rarely covered by work-­related social health insurance schemes, and where they are, they obtain lower benefits due to their lower earnings. At the same time neoliberal policy reduced social provisioning of food, water and health services, and this had particular impacts on the time constraints faced by the poorest women. Berik et al. (2009) argue that women in low-­income groups are forced into low-­income employment while also putting in more time and effort to find other ways to meet basic needs. Mackintosh and Tibandebage (2006) make a similar point, arguing that the income and time constraints faced by low-­income women lead them to creating a vicious circle. Women’s access to health care is constrained not only by the demands placed on their time, but also by their inability to afford quality health services in liberalized health care systems. Time constraints are one way to understand the outcome, but Gideon (2008: 79) reminds us that time constraints are very uneven for richer and poorer women, and that time does not map on neatly to welfare, with care work done by women inducing far higher stress levels than other kinds of unpaid work within the household. This overview of the impact of neoliberal policy suggests that even where economic growth has occurred, the pattern of this growth has had negative impacts for the welfare of poor and marginalized women in particular. This has been a result of the casualization of employment and loss of labour rights, coupled with the commodification of basic social services. While there may have been mixed income effects, time constraints have increased and it has been harder to access health and other social services.

NEOLIBERAL SOCIAL PROTECTION POLICY AND THE MOVE TO CASH TRANSFERS Changes in social protection policy have had important impacts on gendered claims over public and private health care. The advent of neoliberal social policies in the 1980s represented an ideological break with previous systems of social provision. As MacGregor (2005) has argued, no advanced country had a full welfare state, and there were important differences between countries. Scandinavia’s wide and deep welfare system can be contrasted by the residual welfare state of the US, with most other advanced democracies falling somewhere between the two. After the 1980s, social protection spending changed significantly in certain advanced countries, while in others the real value of government spending may have changed little (MacGregor, 2005). However if social protection expenditure did not collapse dramatically in all advanced countries with the advent of neoliberal policy, it is clear that ideology changed significantly (MacGregor, 2005). With more responsibility left to the individual and the supposedly superior private sector, welfare policy was now crafted with the idea that it must not hamper the working of the market by setting poverty traps, raising production costs and reducing flexibility. This change in ideology was also influential in low-­and middle-­income countries, not least because they were under increased pressure to conform to the agenda of neoliberal institutions, such as the World Bank and IMF. By the 1980s, only a few low-­and middle-­income countries had had extensive welfare states, and these were rolled back further (Molyneux, 2007; Gideon, 2008; Saad-­Fihlo, 2014). In middle-­income ­countries,

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Neoliberal policy, health and gender  ­105 reformed welfare systems often discriminated against blue-­ collar workers and poor women in particular, limiting access to schemes and compounding this by making benefits dependent on income. In low-­income settings, the cuts in spending to already limited welfare systems were even more dramatic. Evidence about the impact of policy reform and liberalization on the poor led to considerable concern among some non-­ governmental organizations (NGOs), academics and policy-­makers. A range of publications sought to document the negative impact on the poor of neoliberal policies. For example, in an influential academic publication linked to the United Nations Children’s fund (UNICEF), Cornia et al. (1988) discussed the human cost of liberalization in less-­ developed countries. Cornia et al. highlighted the detrimental impact on purchasing power of the poor caused by cuts in subsidies (especially for food) and increases in user charges for government services in the areas of health and education. In many countries, public sector employment (and wages) had been drastically cut back, while private sector employment had rarely expanded to offset this. Cash Transfers as Social Protection These growing concerns about poverty and inequality within and outside neoliberal ­institutions led slowly to new approaches to neoliberal social protection policy ­(Saad-­Filho and Johnston, 2005). One important widely adopted set of interventions involves the use of non-­contributory social benefit payments on a conditional or unconditional basis. Programmes can be variously universal (available to all) or targeted (available to a selected group), conditional (disbursed only if the recipient follows a particular action) or unconditional (disbursed to anyone in the target group). Cash transfers have been used extensively in a range of countries and in most regions of the world, funded both from domestic sources and by aid donors, and rough estimates (based on compendium work by Barrientos and Niño-­Zarazúa, 2010) suggest that between 0.75 billion and 1 billion people in low-­and middle-­income countries currently receive non-­contributory cash benefits. For example, Garcia and Moore (2012) estimate that, partly as a result of donor promotion, the number of cash transfer schemes in African countries has increased from 21 (in 9 countries) in 2000 to 245 programmes (in 41 ­countries) in 2012. The largest is the Ethiopian Productive Safety Net Programme which reaches around 7 million households (Barrientos and Niño-­Zarazúa, 2010) and around 10 per cent of the population (Ruel and Alderman, 2013). In Latin America, the largest cash transfer programme is the Brazilian Programa Bolsa Família (Family Grant, PBF), reaching 12 million households in 2009 (Barrientos and Niño-­Zarazúa, 2010) and laying claim to having encouraged the growth of non-­contributory cash transfer schemes internationally (Saad-­Filho, 2014). The reformed neoliberal social protection approach changes the discourse on poverty. While Hanlon et al. (2010) argue that cash transfers offer an elegant Southern alternative to the aid industry, others have argued that they represent an intensification of the neoliberal ideology of commodification. Poor people will participate more effectively in markets with greater education and better health, and can use cash transfers to gain those benefits. As Saad-­Filho (2014) writes, cash transfers are complementary to the extension of the market provision of public goods such as education, health and transport, as they bring the poor into the market for newly privately-­provided services.

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106  Handbook on gender and health Cash transfers have had varied aims, target groups, generosity, designs and conditionalities. Changes in the ability to access health services and in health outcomes have been both direct and indirect outcomes. We might expect cash transfers to increase income, but sometimes programmes specifically require the use of nutrition or health services (as conditions of cash receipt), involve nutrition or health education, specifically target vulnerable members or are delivered at moments of vulnerability (that is, due to seasonal factors or in complex emergencies). A range of quantitative and qualitative information is available on the impact of transfers and several meta-­reviews have been carried out, albeit exclusively focusing on evidence from randomized control trials (RCTs) with much evidence drawn from Latin America. RCT exercises are carried out to investigate the impact on an intervention by comparing the outcomes for participants with those for a ‘control’ group. Arguably these exercises wrongly privilege certain kinds of quantitative information, have a narrow focus and are poor at understanding causal links (Deaton, 2010; Basu, 2013; Cartwright and Hardie, 2012). So while they can give headline figures for certain transfer schemes, they often cannot explain outcomes. Cash transfers appear to have positive effects on household food consumption and dietary diversity, while conditional cash transfers specifically increase awareness of health messages, immunization rates, and use of health and nutrition services (Ranganathan and Lagarde, 2012; Gaarder et al., 2010; Ruel and Alderman, 2013). However, evidence of effects on health and nutritional outcomes is mixed. Meta-­analysis suggests that there have been no statistically significant effects of either conditional or unconditional transfers on child anthropometry overall (Ruel and Alderman, 2013). Information for individual programmes supports this, suggesting that only a few programmes have effects on bodily outcomes, and these have tended to be for the youngest or poorest children or those on the project for longer (Ruel and Alderman, 2013). Aside from specific impacts on macro-­and micro-­nutrients, little data have been collected on other health outcomes and even less show significant changes. Ruel and Alderman (2013) report reductions in obesity and hypertension among adults participating in the Mexican programme, Oportunidades. Lagarde et al. (2007) cite mixed evidence of the effect of Oportunidades on anaemia in children, but a significant reduction in reported illness in younger children in Colombia and Mexico. Several reasons have been given for the lack of impact on nutritional and health outcomes, given that health service use increases in most cases (Ruel and Alderman, 2013). There may be a statistical basis: that most programmes with RCTs are in middle-­income countries while programmes in low-­income countries might be more effective. More fundamentally it has been argued that programmes might be poorly designed, too short or not generous enough. Finally, the lack of correlation between increased use of nutritional and health services, and improved health and nutritional outcomes, might be an indicator of poor services (Ranganathan and Lagarde, 2012; Ruel and Alderman, 2013). Aside from health outcomes and use of services, other health behaviours have also been targeted by cash transfers. For example, some social protection cash transfers have claimed to have achieved reductions in HIV risk. Where transfers are conditional, these have often been premised on school attendance and can be universal or targeted (for example, only to young people, households with an income below a certain threshold or only to girls in a certain region). Examples below have been implemented in Kenya and in Malawi (Johnston, 2015). The link to HIV risk behaviours has been made through

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Neoliberal policy, health and gender  ­107 education, poverty reduction and women’s empowerment. Handa et al. (2014: e85473) set out these channels, arguing that ‘cash transfers may reduce the risk of HIV by addressing structural risk factors, especially poverty, vulnerability and low human capital’. Greater educational attendance is seen as reducing HIV risk directly, as sex is imagined to be less likely in school; and indirectly, as young people will receive HIV education and may be more likely to partner with those of the same age (rather than older partners who may have already acquired HIV). At the same time, Handa et al. (2014) suggest that HIV risk is reduced through a poverty channel, as cash transfers may postpone sexual debut by reducing poverty and making young women less dependent on male partners, reducing sex acts generally and unprotected sex in particular. Finally, they consider that lifting households out of the deepest poverty might increase hope for the future, and so increase interest in risk reduction. A similar framework that links both poverty reduction and women’s empowerment to reduced HIV risk is set out by Heise et al. (2013: 2). The Kenyan cash transfer Programme for Orphans and Vulnerable Children appears to have reduced the age of sexual debut. During the pilot stage (where it was not rolled out to the whole country), it was possible to find a comparator group, with the comparison suggesting that young recipients (aged 15–25) had a 23 per cent lower rate of sexual debut than others (Handa et al., 2014). Handa et al. (2014) contend that this was the result of better school attendance, with secondary school-­age participants eight percentage points more likely to be in school than the control. However there is room for some hesitation about the impact. Self-­reported data on sexual debut of course has limitations, while not much is known about the long-­run impact of delayed sexual debut. Do individuals go on to face reduced risks over their lifetime (Handa et al., 2014)? Understanding the sexual debut results is important as, worryingly, the transfer had no other impacts on HIV risk, with indicators such as condom use, number of sexual partners, transactional sex and so on being unaffected. In the Malawi Schooling, Income, and HIV Risk (SIHR) project a complex set of comparisons are constructed with a control group and several different intervention groups. All young women who were baseline school dropouts received money conditional on school attendance. Then the group of girls attending school at the baseline was divided into three. Some received conditional transfers; some received unconditional transfers; and in some areas, only baseline dropouts received transfers while baseline school girls did not (Baird et al., 2012). Baird et al. (2012) reported a decrease in the prevalence of HIV and herpes simplex virus (HSV) compared to the control group, but this was only for girls who were at school at the baseline. Self-­reported evidence suggested that it reduced the number of partners and reduced the number of times girls had sex. However it had no effect on condom use or age of sexual debut. The researchers estimate that the change in HIV status for the intervention group was the result of two factors: reduced frequency of sex, and lower-­risk sexual partners, specifically that the partners of girls in the intervention group were one year younger on average than those in the control. The size of the transfer did not seem to affect the impact on HIV or HSV. However, this intervention also raised questions. First, some authors have doubted that lower HIV rates were due solely to the choice of older partners. Heise et al. (2013: 3) note that only 2.5 per cent of girls in the control group versus 0.5 per cent of girls in the intervention groups had older sexual partners, and thus the small reduction in age of partners could not explain the difference in HIV prevalence. Moreover girls in the conditional arm had the same teen pregnancy

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108  Handbook on gender and health and marriage rates as the control group (Baird et al., 2012). Given the lack of impact on sexual debut and condom use, the mechanisms for impact seem a little unclear. Finally, the intervention had no impact on HIV or HSV rates for girls who were dropouts at the baseline. The project has planned a long-­run impact study which had not been published at the time of writing in February 2015. Overall the impact of social protection cash transfers on HIV-­related behaviour is not clear-­cut. It should be noted that the Malawi project was focused on girls and many other cash transfers focus on girls (in order to affect their future sexual or childcare behaviour) or on women who are currently mothers. Much of the latter is based on the belief in differential spending patterns between men and women, with women supposedly more inclined to spend on household welfare goods. Saad-­Filho (2014) reports that 95 per cent of the recipients of Oportunidades are female, for example. Interestingly, the evidence on whether women and men spend cash transfers differently is quite limited and methodologically difficult to interpret. Kabeer et al. (2012) report that transfers to women in couple-­headed households resulted in higher-­quality nutritional intake and increased purchases of children’s clothing compared to households headed by a single parent, whether male or female. They conclude that this is evidence that women spent cash very differently from men. Gaarder et al. (2010) argue that some comparisons are inappropriate. For example, one study compared the impact of the Progresa programme (in which a female was the recipient) to the Procampo programme (where the recipient was often male). The Progresa intervention led to larger improvements in health and education than Procampo, suggesting that the gender of the recipient was important. However, Gaarder et al. (2010) argue that the two programmes were vastly different in terms of conditionality around health and education, and that these conditionalities are as important as gender in explaining different spending patterns. In trying to understand the gendered impact of these social protection cash transfers, we need to consider several divergent factors. First, cash transfers might change the labour and time constraints faced by men and women differently. Kabeer et al. (2012) hypothesize that an increase in girls’ school attendance may reduce their time for domestic chores, with a knock-­on effect on their mothers’ time constraints. Women may also find that they have to bear the time burden of meeting conditionalities, such as clinic attendance for young children. Similarly, an increase in boys’ schooling might reduce their paid work, although the gendered implications for adults in the household are less clear. In some settings men might need to increase working hours, in others women might increase their hours. In Kabeer et al.’s (2012) study there is limited evidence, but their meta-­analysis suggests that conditional cash transfers have a bigger impact on reducing girls’ labour than on boys. The evidence on the time allocation of adult women and men is more mixed, and it was hard for the authors to draw firm conclusions. Overall Kabeer et al. (2012) suggest that the impact on adults’ labour was smaller and that it may be that women’s time allocation was more sensitive to the receipt of the transfer than men’s. Second, the social status of women and men may change according to the gender of the recipient of the cash transfer. The targeting of many transfers to female recipients is seen as empowering women by raising their self-­esteem, increasing their financial independence and community perceptions. However others have argued that cash transfers propagate stereotypical views that women are responsible for household welfare. Cash transfers therefore may not be emancipatory, and instead cement unequal gendered

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Neoliberal policy, health and gender  ­109 norms. Saad-­Filho (2014) paints a critical picture, where women find their caring role consolidated while also fulfilling government-­ imposed conditionalities. Arguably we cannot generalize the impact of cash transfers on changing gender norms, as these transfers must be understood in their specific setting (Molyneux, 2007; Molyneux and Thomson, 2011; Ghosh, 2011). Cash Transfers as Incentive-­Changers If the discussion above suggests that the gendered impacts of cash transfers on health and on social norms needs close investigation, the introduction of a new breed of cash transfer reinforces this. The interventions discussed above were developed in a social protection framework. However cash transfers are also being designed from a behavioural economics approach, where the transfer does not aim to reduce poverty but rather to change specific incentives around health behaviour (World Bank, 2015). Behavioural economics sees people as economic agents, some of whom are myopic and so ignore health messages, because they heavily discount the future benefits of health-­ seeking activity and instead overly value their current pleasure. For example, it might be argued that myopic individuals will not choose to eat healthily because they focus on the immediate pleasure of unhealthy food and do not concern themselves with future benefits of a balanced diet; or that these individuals will not complete a course of tuberculosis (TB) treatment as they will focus on the immediate costs of repeated hospital attendance; or that they will not engage in safe sex as they will wrongly discount the cost of acquiring HIV and will focus on the pleasure of unsafe sex. Pykett (2012) has provided a feminist critique of the behaviour change narrative, focusing on the way in which it is hinged on a simplistic dichotomy between emotion and reason. She argues not only that this dualistic thinking should be challenged but also, more importantly, that attention should instead be paid to the way in which social structures and power relations shape conduct. While behavioural economics provides the framework for analysing the behaviour of individuals, the project of changing the incentives of the supposedly myopic has been developed by libertarian paternalists, so named because they argue that small changes to incentives essentially leave the individual with an untrammelled ability to exercise choice, while ensuring that outcomes are more likely to be in their self-­interest (Santos, 2011). The leading example of this kind of work is that by Thaler and Sunstein (2008), which has influenced national and local governments in Northern countries to subtly ‘nudge’ individual behaviour (Cromby and Willis, 2014; Pykett, 2012). Libertarian paternalism has had a less subtle form in certain instances. Borrowing from psychologists who use cash transfers to change behaviours such as smoking and substance abuse, health-­ focused interventions can operate through tightly designed frameworks of conditionality and reward. Specifically conditional cash transfers are seen as changing the balance between short-­and long-­run benefits so that individuals are more likely to choose healthy practices, such as safe sex (de Walque et al., 2012b: 2). First, incentives could operate by increasing and bringing forward the implicit price of unsafe sex (through the immanent loss of the cash reward). Second, even if the amounts of cash are small, regular payments could still ‘“nudge” individuals to overcome inertia and extricate themselves from unduly risky sexual relationships’ (de Walque et al., 2012b: 2). Third, de Walque et al. (2012a: 14) also suggest that cash incentives provide individuals

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110  Handbook on gender and health with an excuse for deviating from social norms in order to act on underlying preferences for less risky behaviour. Ill-­health is therefore seen as the result of suboptimal decisions by certain individuals (who mistakenly believe themselves to be making optimal decisions), who can manage this by changing their choices. Several examples of health-­incentive transfers can be identified. Ranganathan and Lagarde (2012) report on two programmes seeking to promote safe motherhood by paying patients, staff and institutions. In Nepal, the Safe Delivery Incentive Programme increased the use of skilled attendance at delivery and reduced the probability of a woman delivering at home. In India, the Janani Suraksha Yojana programme increased the uptake of antenatal care, substantially increasing the proportion of women giving birth in health facilities. Both worked by paying health workers for each attending patient, and also paying patients for the use of health services. Ranganathan and Lagarde (2012) also report on a project in Malawi that paid individuals to pick up HIV test results. Beith et al. (2009) discuss incentives to improve TB detection and treatment adherence in the United States (US), Russia, Cambodia, Bangladesh, Tajikistan, Indonesia, Bolivia, Brazil, the Czech Republic, El Salvador, India and Haiti. They argue that where programmes are well designed, they can increase detection and treatment adherence. Two projects to change HIV risk behaviours have been designed, one in Lesotho and one in Tanzania (Johnston, 2015). In the Lesotho intervention the designers, ­Björkman-­Nyqvist et al. (2013), argue that certain people engage in risky sexual behaviour despite a high background level of HIV because they weigh short-­term gains more highly than long-­term benefits. Similarly, referring to young people involved in the Tanzania RESPECT project, de Walque et al. (2012a: 6) conclude that: ‘[t]hese young people appear to understand their HIV risks and know how to behave to prevent ­transmission – yet they don’t choose to act on that knowledge’. These projects have very different kinds of conditionality to those reported for general social protection programmes seeking to also reduce HIV risk. A poverty-­focused intervention based on the development approach may have no conditionality or might be conditional on school attendance. However interventions informed by behavioural economics are premised on a far more tailored conditionality in order to incentivize behaviour change. The frequency of the reward is seen as being more important than its size. De Walque et al. (2012a: 14) and Medlin and de Walque (2008: 5) argue that if people have high rates of discount (and are thereby at risk of acquiring HIV), they value quick pay-­offs, and so awarding a transfer after a long wait time will be ineffective. As such, behavioural economics interventions will have much smaller cash transfers than social protection interventions. There are also frequent sexually transmitted infection (STI) tests, and in practice HIV itself is not used as an indicator (Medlin and de Walque, 2008: 12–13). Background HIV rates are low in many settings (for example, de Walque et al., 2012a: 12–13) meaning that risky sexual behaviour may not always lead to HIV acquisition. At the same time HIV has an incubation period of several months and so testing positive is seen as too distant from unsafe sex. So the Lesotho and Tanzania projects require that participants remain free of certain other sexually transmitted infections that can be tested cheaply using an onsite or convenient laboratory. In the Tanzania RESPECT Study, there were two sizes of cash transfer. At the end of 12 months only the higher-­payment group had a statistically significant difference in STI prevalence compared to the control group (de Walque et al., 2012b), with a

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Neoliberal policy, health and gender  ­111 25 per cent reduction compared to the control group in four easily tested and curable STIs. Nonetheless the data on three other STIs (HSV, syphilis and, crucially, HIV) showed no significant difference (de Walque et al., 2012b: 8), casting doubt on the link between the four indicator STIs and HIV risk. It was not clear whether the study encouraged sexual behaviour change or whether it was about change in the treatment sought for the four curable STIs. The long-­term impacts are crucial but had not yet been published at the time of writing in February 2015. However a conference paper quoted by another author (Heise et al., 2013: 4) appears to have reported that one year after the initial evaluation the results had been maintained in men but not women. In the Lesotho project, syphilis and  Trichomonas vaginalis were chosen as proxies for risky sex (Björkman-­Nyqvist et al., 2013). Participants did not receive a guaranteed payment but rather a chance to enter a lottery, with different amounts of winnings depending on the intervention streams. Two years after the project started, HIV incidence was significantly lower among the study participants, especially for women and for the group who could enter the lottery for the highest winnings (Björkman-­Nyqvist et al., 2013). It will be crucial to note the results of longer-­term impacts once those are reported. To review the findings on health-­incentive transfers, there is mixed evidence on their effectiveness, but some programmes do seem to have achieved their desired aims. Ethical issues are raised by their design, specifically whether inclusion and exclusion can be justified and whether the intrusion of their interventions is outweighed by the benefits (Johnston, 2015). Another key concern is sustainability after the end of the intervention, and this is an area of limited data. In the Tanzanian RESPECT study, after two years the impact on STI acquisition by women vanished. Rigsby et al. (2000) studied the impact of a four-­week cash transfer project on anti-­retroviral drug adherence among a sample of US veterans. While the use of monetary reinforcement clearly helped treatment adherence during the project, eight weeks after its end adherence in the cash transfer group had returned to near baseline levels. More than that, underlying these interventions is a theory of health that focuses on poor choices by individuals. This obscures the social and economic forces that produce ill-­health. The libertarian paternalist version of behavioural economics blames ill-­health on faulty discount rates (that is, the inability to properly respond to health messages). These projects set out to change only the way that people make choices. However the wider set of factors leading to poor health is ignored: factors related to the public and private provision of health care, or the economic and social relations of production. As Mehta (2013: 1243) argues generally about libertarian paternalism, the ‘upsurge of interest in behavioural remedies distracts attention from facets of the individual’s environment, such as the characteristics of markets and the behaviour of firms, and also the set of norms and beliefs underpinning the economic system’. Specifically, behavioural economics does not recognize the role of systematic (rather than individual) factors in explaining poor health, which are diverse, specific to particular health conditions and in some cases deeply political. Consequently it is not surprising that cash transfer projects have had such complex and sometimes limited impacts, and that they are attractive to policy-­makers. After all, the oversimplified premise of these projects edits out politically difficult questions of power, distribution and class. As Harman (2011: 879) argues, ‘[c]ash transfers perform key roles essential to the main paradigm of global health: they

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112  Handbook on gender and health are performance oriented, show measurable results, engage in social protection and can be replicated in multiple different contexts’.

CONCLUSION This chapter has argued that if you want to understand neoliberal policy, gender and health, you need a wide lens that encompasses neoliberal health reform, economic policy and social protection policies. We have seen that neoliberal policy has changed gendered access to health services due to the combination of user charges and co-­production for public health service access, in an environment where many women have had limited access to the kind of employment that generates sick leave or private health insurance. The limitations of new systems of health provision are likely to have increased women’s time constraints as they attempt to increase both economic activity and reproductive activity. Social protection interventions in some settings may even have cemented disadvantageous social norms around household responsibilities and increased women’s time constraints. Neoliberal policy has also changed the definitions of health rights, with health seen as co-­produced by the state, the private sector and the individual. In the more recent flirtation with libertarian paternalism, there has been an even stronger emphasis on seeing health as the outcome of individual choice. A feminist political economy approach to health would instead consider the production of affliction. By recognizing the need for a change in the social and economic organization of the economy, an inherently political analysis is produced; one with very different conclusions to the menu of behaviour change interventions. Certainly, the reviews contained in this chapter would support Razavi’s (2007) call for non-­contributory citizen-­based or residence-­based health entitlements for women, men, girls and boys. These entitlements would be built into a system where investments are made in the supply side of the health system. More than this, a regulatory system would be necessary to ensure decent work. This chapter has shown that while these proposals might seem radical, it is only by decommodifying health entitlements that we can proceed to improve the health outcomes for poor women and men. As well as the constraints on health expenditure, low-­and middle-­income countries are hamstrung in any attempts to correct patterns of uneven development or to stimulate their productive sectors. Patterns of neoliberal growth have led to rising income inequality, experienced not only as gendered inequality but also as inequalities between different classes and races. However, many countries have little leeway in terms of active trade and industrial policy due to World Trade Organization rules, aid conditionality and trade-­related aspects of intellectual property rights (TRIPS). In the place of a far-­ reaching policy agenda to change health risks, cash transfers have become a popular intervention. These extend the commodification of health and welfare further, while allowing governments greater intrusion in the behaviour of individuals. This intrusion is justified by the supposed benefits of cash transfers, although it is not clear whether they can lead to sustained change. It is worrying that, at the same time, cash transfers may have cemented unequal gendered norms over the responsibility for household welfare.

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Neoliberal policy, health and gender  ­113

NOTE 1. For example, health-­related libertarian paternalism in the North might focus on the way that a change to the layout of school canteens can increase the uptake of fruit and vegetables (http://www.sciencedaily.com/ releases/2013/02/130226172506.htm, accessed 10 November 2014).

REFERENCES Abimbola, S., J. Negin, S. Jan and A. Martiniuk (2014), ‘Towards people-­centred health systems: a multi-­level framework for analysing primary health care governance in low-­and middle-­income countries’, Health Policy and Planning, 29 (Suppl. 2): ii29–ii39. Baird, S.J., R.S. Garfein, C.T. McIntosh and B. Özler (2012), ‘Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial’, Lancet, 379 (9823): 1320–1329. Barrientos, A. and M. Niño-­Zarazúa (2010), Effects of Non-­Contributory Social Transfers in Developing Countries: A Compendium, Geneva: ILO. Basu, K. (2013), ‘The method of randomization, economic policy, and reasoned intuition’, World Bank Policy Research Working Paper NO 6722, Washington, DC: World Bank. Beith, A., R. Eichler and D. Weil (2009), ‘Worldwide: incentives for tuberculosis diagnosis and treatment’, in R. Eichler and R. Levine (eds), Performance Incentives for Global Health: Potential and Pitfalls, Washington, DC: Center for Global Development, pp. 237–256. Berik, G., Y. van der Meulen Rodgers and S. Seguino (2009), ‘Feminist economics of inequality, development, and growth’, Feminist Economics, 15 (3): 1–33. DOI: 10.1080/13545700903093524. Björkman-­Nyqvist, M., L. Corno, D. de Walque and J. Svensson (2013), ‘Evaluating the impact of short term financial incentives on HIV and STI incidence among youth in Lesotho: a randomised trial’, Sexually Transmitted Infections, 89 (Suppl. 1): A325. DOI:10.1136/sextrans-­2013-­051184.1017. Cartwright, N. and J. Hardie (2012), Evidence-­Based Policy: A Practical Guide to Doing It Better, New York: Oxford University Press. Cornia, G.A. (2004), ‘Inequality, growth and poverty: an overview of changes over the last two decades’, in G.A. Cornia (ed.), Inequality, Growth and Poverty in an Era of Liberalization and Globalization, Oxford, UK and New York, USA: UNU-­WIDER, pp. 3–24. Cornia, G.A., R. Jolly and F. Stewart (1988), Adjustment with a Human Face: Protecting the Vulnerable and Promoting Growth, New York: Oxford University Press. Cornwall, A., Gideon, J. and K. Wilson (2008), ‘Introduction: reclaiming feminism: gender and neoliberalism’, IDS Bulletin, 39 (6): 1–9. Cromby, J. and M.E.H. Willis (2014), ‘Nudging into subjectification: governmentality and psychometrics’, Critical Social Policy, 34 (241). DOI: 10.1177/0261018313500868. Cutler, D., A. Deaton and A. Leras-­Muney (2006), ‘The determinants of mortality’, Journal of Economic Perspectives, 20 (3): 97–120. Deaton, A. (2003), ‘Health, inequality, and economic development’, Journal of Economic Literature, 41 (1): 113–158. Deaton, A. (2010), ‘Instruments, randomization, and learning about development’, Journal of Economic Literature, 48 (2): 424–455. DOI: 10.1257/jel.48.2.424. Dennis, S. and E. Zuckerman (2008), ‘Mapping multilateral development banks’ reproductive health and HIV/ AIDS spending’, Gender and Development, 16 (2): 287–300. Durevall, D. and A. Lindskog (2009), ‘Economic inequality and HIV in Malawi’, University of Gothenburg, School of Business, Economics and Law, Working Paper No 425. Available at http://www. economics.handels.gu.se/digitalAssets/1374/1374716_ineqaulity_hiv_wp425.pdf (accessed 1 December 2012). Evans, T. (2002), ‘A Human Right to Health?’, Third World Quarterly, 23 (2), 197–215. Fine, B. (2009), ‘Social policy and the crisis of neo-­liberalism’, paper presented at The Crisis of Neo-­Liberalism in India: Challenges and Alternatives Conference, Tata Institute of Social Sciences (TISS) Mumbai and International Development Economics Associates (IDEAs), March. Available at http://www.networkideas. org/ideasact/jan09/PDF/Fine.pdf (accessed 26 October 2011). Fine, B. and P. Rose (2001), ‘Education and the post-­Washington consensus’, in B. Fine, C. Lapavitsas and J. Pincus (eds), Development Policy in the Twenty-­first Century: Beyond the Post-­Washington Consensus, London, UK and New York, USA: Routledge, pp. 155–181.

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114  Handbook on gender and health Freedman, L.P. (2005), ‘Achieving the MDGs: health systems as core social institutions’, Development, 48 (1): 19–24. Gaarder, M.M, A. Glassman and J.E. Todd (2010), ‘Conditional cash transfers and health: unpacking the causal chain’, Journal of Development Effectiveness, 2: 6–50. Garcia, M. and C.M. Moore (2012), The Cash Dividend: The Rise of Cash Transfer Programs in Sub-­Saharan Africa, Washington, DC: World Bank. Ghosh, J. (2011), ‘Cash transfers as the silver bullet for poverty reduction: a sceptical note’, Economic and Political Weekly, 46 (21): 67–71. Gideon, J. (2008), ‘Counting the cost of privatised provision: women, rights and neoliberal health reforms in Chile’, IDS Bulletin, 39 (6): 75–82. Handa, S., C.T. Halpern, A. Pettifor and H. Thirumurthy (2014), ‘The government of Kenya’s cash transfer program reduces the risk of sexual debut among young people age 15–25’, PLoS ONE, 9 (1): e85473. Hanlon, J., A. Barrientos and D. Hulme (2010), Just Give Money to the Poor, Sterling, VA: Kumarian Press. Hanmer, L., R. Lensink and H. White (2003), ‘Infant and child mortality in developing countries: analysing the data for robust determinants’, Journal of Development Studies, 40 (1): 101–118. Harman, S. (2011), ‘Governing health risk by buying behaviour’, Political Studies, 59, 867–883. DOI: 10.1111/j.1467-­9248.2011.00920.x. Heise, L., B. Lutz, M. Ranganthan and C.Watts (2013), ‘Cash transfers for HIV prevention: considering their potential’, Journal of the International Aids Society, 16 (1): 18615. DOI: 10.7448/IAS.16.1.18615. Hickel, J. (2012), ‘Neoliberal plague: the political economy of HIV transmission in Swaziland’, Journal of Southern African Studies, 38 (3): 513–529. Johnston, D. (2015), ‘Paying to reduce HIV in Africa: cash transfers and the de-­politicisation of HIV risk’, Review of African Political Economy, Special Issue on Political Economy of HIV, 42 (14): 394–413. Kabeer, N.  (2008),  ‘Paid work, women’s empowerment and gender justice: critical pathways of social change’, Pathways of Empowerment Working Papers, 3, Brighton: Institute of Development Studies. Kabeer, N., C. Piza and L. Taylor (2012), What are the Economic Impacts of Conditional Cash Transfer Programmes: A Systematic Review of the Evidence, London: EPPI-­Centre, Social Science Research Unit, Institute of Education, University of London. Kenny, C. (2005), ‘Why are we worried about income? Nearly everything that matters is converging’, World Development, 33 (1): 1–19. Knowles, S. and P.D. Owen (2010), ‘Which institutions are good for your health? The deep determinants of comparative cross-­country health status’, Journal of Development Studies, 46 (4): 701–723. Kucera, D. and S. Tejani (2014), ‘Feminization, defeminization, and structural change in manufacturing’, World Development, 64: 569–582. Available at http://dx.doi.org/10.1016/j.worlddev.2014.06.033. Lagarde, M., A. Haines and N. Palmer (2007), ‘Conditional cash transfers for improving uptake of health interventions in low-­and middle-­income countries: a systematic review’, JAMA, 298: 1900–1910. Leigh, A., C. Jencks and T.M. Smeeding (2009), ‘Health and economic inequality’, in W. Salverda, B. Nolan and T.M. Smeeding (eds), The Oxford Handbook of Economic Inequality, Oxford: Oxford University Press, pp. 442–475. Leys, C. (2010), ‘Health, health care and capitalism’, in L. Panitch and C. Leys (eds), Socialist Register 2010: Morbid Symptoms Under Capitalism, London: Merlin Press, pp. 1–28. MacGregor, S. (2005), ‘The welfare state and neoliberalism’, in A. Saad-­ Filho and D. Johnston (eds), Neoliberalism – A Critical Reader, London: Pluto Press, pp. 142–148. Mackintosh, M. and P. Tibandebage (2006), ‘Gender and health sector reform: analytical perspectives on African experience’, in S. Razavi and S. Hassim (eds), Gender and Social Policy in a Global Context: Uncovering the Gendered Structure of ‘the Social’, Social Policy in a Development Context Series, Basingstoke: Palgrave Macmillan, pp. 237–257. Marmot, M. (2005), ‘Social determinants of health inequalities’, Lancet, 365: 1099–1104. Medlin, C. and D. de Walque (2008), ‘Potential applications of conditional cash transfers for the ­prevention  of sexually transmitted infections and HIV in Sub-­Saharan Africa’, Human Development and Public Services Team, World Bank Policy Research Working Paper 4673, Washington, DC: World Bank. Mehta, J. (2013), ‘The discourse of bounded rationality in academic and policy arenas: pathologising the errant consumer’, Cambridge Journal of Economics, 37, 1243–1246. DOI: 10.1093/cje/bet040. Molyneux, M. (2007), ‘Two cheers for CCTs’, IDS Bulletin, 38 (3): 69–74. Molyneux, M. and M. Thomson (2011), ‘Cash transfers, gender equity and women’s empowerment in Peru, Ecuador and Bolivia’, Gender and Development, 19 (2): 195–212. Noormahomed, A.R. and M. Segall (1994), The Public Health Sector in Mozambique: A Post-­war Strategy for Rehabilitation and Sustained Development, WHO Macroeconomics, Health and Development Series No. 14, Geneva: World Health Organization. Available at http://apps.who.int/iris/handle/10665/62120 (accessed 1 December 2012).

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Neoliberal policy, health and gender  ­115 O’Laughlin, B. (2013), ‘Land, labour and the production of affliction in rural Southern Africa’, Journal of Agrarian Change, 13 (1): 175–96. DOI: 10.1111/j.1471-­0366.2012.00381.x. Ostrom, E. (1996), ‘Crossing the great divide: coproduction, synergy, and development’, World Development, 24 (6): 1073–1087. Pandolfelli, L.E., J. Shandra and J. Tyagi (2014), ‘The International Monetary Fund, structural adjustment, and women’s health: a cross-­national analysis of maternal mortality in Sub-­Saharan Africa’, Sociological Quarterly, 55 (1): 119–142. Parsitau, D.S. (2008), ‘The impact of Structural Adjustment Programmes (SAPs) on women’s health in Kenya’,  in M. Sama and V. Nguyen (eds), Governing Health Systems in Africa, Senegal: Council for the Development of Social Science Research in Africa, pp. 191–200. Payne, S. and L. Doyal (2010), ‘Re-­visiting gender justice in health and healthcare’, in E. Kuhlmann and E. Annandale (eds), The Palgrave Handbook of Gender and Healthcare, Basingstoke, UK and New York, USA: Palgrave Macmillan, pp. 21–35. Pérez, C.B. and X. Ramos (2010), ‘Polarization and health’, Review of Income and Wealth, 56 (1): 171–85. Pritchett, L. and L. Summers (1996), ‘Wealthier is healthier’, Journal of Human Resources, 31 (4): 841–866. Pykett, J. (2012), ‘The new maternal state: the gendered politics of governing through behaviour change’, Antipode, 44 (1): 217–238. Ranganathan, M. and M. Lagarde (2012), ‘Promoting healthy behaviours and improving health outcomes in low and middle income countries: a review of the impact of conditional cash transfer programmes’, Preventive Medicine, 55: S95–S105. Razavi, S. (2007), ‘The political and social economy of care in a development context’, Gender and Development Programme Paper 3, Geneva: UNRISD. Rigsby, M.O., M.I. Rosen, J.E. Beauvais, J.A. Cramer, P.M. Rainey, S.S. O’Malley, K.D. Dieckhaus and B.J.  Rounsaville (2000), ‘Cue-­dose training with monetary reinforcement: pilot study of an antiretroviral adherence intervention’, Journal of General Internal Medicine, 15 (12): 841–847. Rowden, R. (2008), ‘Blocking progress: the IMF and HIV/AIDS’, Global Social Policy, 8: 19–24. Rowden, R. and N. Thapliyal (2007), ‘IMF still blocking progress on HIV/AIDS, health and education: new report outrages aid advocates’, Policies and Priorities, 2 (1). Available at http://www.ifiwatchnet.org/?q=en/ node/2731 (accessed 5 March 2008). Ruel, M.T. and H. Alderman (2013), ‘Nutrition-­sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition?’, Lancet, 382 (9891): 536–551. Saad-­Filho, A. (2014), ‘Social policy for mature neoliberalism: the Bolsa Família programme in Brazil’, Mimeo. Saad-­Filho, A. and D. Johnston (2005), Neoliberalism: A Critical Reader, London: Pluto Press. Santos A.C. (2011), ‘Behavioural and experimental economics: are they really transforming economics?’, Cambridge Journal of Economics, 35: 705–728. DOI:10.1093/cje/beq049. Sen, G. and A. Mukherjee (2014), ‘No empowerment without rights, no rights without politics: gender-­equality, MDGs and the post-­2015 Development Agenda’, Journal of Human Development and Capabilities, 15 (2–3): 188–202. DOI:10.1080/19452829.2014.884057. Standing. G. (1999), ‘Global feminization through flexible labor: a theme revisited’, World Development, 27 (3): 583–602. Standing, H. (2007), ‘Gender equity and health indicators in the context of health reforms’, International Journal of Public Health, 52: S5–S6. Standing, H., A. Mushtaque and R. Chowdhury (2008), ‘Producing effective knowledge agents in a pluralistic environment: what future for community health workers?’, Social Science and Medicine, 66 (10): 2096–2107. Stuckler, D. and S. Basu (2009), ‘The International Monetary Fund’s effects on global health: before and after the 2008 financial crisis’, International Journal of Health Services, 39 (4): 771–781. Thaler, R.H. and C.R. Sunstein (2008), Nudge: Improving Decisions about Health, Wealth, and Happiness, London, UK and New York, USA: Penguin Books. de Walque, D., W.H. Dow, C. Medlin and R. Nathan (2012a), ‘Stimulating demand for AIDS prevention: lessons from the RESPECT trail’, National Bureau of Economic Research (NBER) Working Paper 17865, Cambridge, MA: NBER, available online at http://www.nber.org/papers/w17865A (accessed 18 February 2014). de Walque, D., W.H. Dow, R. Nathan, R. Abdul, F. Abilahi, E. Gong, Z. Isdahl, J. Jamison et al. (2012b), ‘Incentivising safe sex: a randomised trial of conditional cash transfers for HIV and sexually transmitted  infection prevention in rural Tanzania’, BMJ Open, 12 (2): e000747. DOI:10.1136/ bmjopen-­2011-­000747. Wilkinson, R. and K. Pickett (2010), The Spirit Level: Why Equality is Better for Everyone, London: Penguin Books.

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116  Handbook on gender and health Willis, K. and S. Khan (2009), ‘Health reform in Latin America and Africa: decentralisation, participation and inequalities’, Third World Quarterly, 30 (5): 991–1005. World Bank (1993), Investing in Health: World Development Report, Washington, DC: World Bank. World Bank (2015), World Development Report 2015: Mind, Society, and Behavior, Washington, DC: World Bank. DOI: 10.1596/978-­1-­4648-­0342-­0. Zia, A.S. (2009), ‘The reinvention of feminism in Pakistan’, Feminist Review, 91: 29–46.

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7.  Applying a genders lens to public health discourses on men’s health

James A. Smith, Noel Richardson and Steve Robertson

INTRODUCTION The state of men’s health is something that continues to generate cause for concern across many areas of the globe. The main concern relates to men’s poorer rates of longevity ­compared to those of women. In the developed world (or ‘Global North’) this difference has been reported in Australia (Australian Institute of Health and Welfare, 2011; ANPHA, 2013), North America (White, 2008; Oliffe et al., 2010), and across Europe (European Commission, 2011; White et al., 2011a). These sex differences – ­inequalities – in longevity across these geographical locations vary tremendously. Within Europe, for example, the lowest difference is found in Iceland where it is 3.3 years; whereas the greatest differences are found in Eastern Europe with Latvia having the largest gap of 11.3 years. Yet it is not just within the Global North that such gender disparities exist. Papers analysing data from the Global Burden of Disease Study 2010 (Horton, 2012) show that across the globe women have longer life expectancy than men. Perhaps more important than longevity is the amount of years spent free from illness or disease; that is, the number of healthy life years that can be expected. In 2010, global male healthy life expectancy at birth was 59.0 years and global female healthy life expectancy 63.2 years (Salomon et al., 2012). Linked to concerns about longevity and healthy life years is the issue of premature mortality. Much of the sex difference in aggregate longevity can be accounted for by such premature death. For example, across the European  Union there are more than twice as many deaths each year at working ages (15–64 years) among men than women. Indeed, deaths in the 15–64 years age group account for 26 per cent of total male deaths compared to 12.6 per cent of female deaths. However, these proportions vary considerably between countries, ranging from nearly 44 per cent of total male deaths occurring in this age group in Lithuania, to 18 per cent in Sweden (European Commission, 2011; White et al., 2011a). The biggest difference in the ratio of male:female deaths across Europe is in the 20–24 years age range where the ratio difference is 3.36 (White et al., 2011a). It is interesting to note that a similar pattern emerges in the USA where there are 396 000 male deaths and 238 000 female deaths across the same age group.1 Although there have been improvements in the life expectancy at birth of men and women in recent years, these improvements have mostly occurred at older ages, reflecting better health outcomes in later life (White et al., 2013). In other words, those who have survived through their working lives are now living longer. There has been little improvement, however, in the high rate of premature death in working age men, which within a European context is particularly pronounced in Eastern European countries (European Commission, 2011). This is an issue not just of public health concern, but also 117 Jasmine Gideon - 9781784710859 Downloaded from Elgar Online at 11/03/2017 02:47:53AM via Sydney University

118  Handbook on gender and health of e­ conomic concern. Population projections suggest that there will be a contraction in the male working population (15–64 years) of some 24 million across the EU-­27 and an expansion of 32 million men over the age of 65 years by 2060 (European Commission, 2011). Thus, a diminishing younger population will have to support an increasing older population. Explanations for sex differences in longevity, healthy life expectancy and premature death vary and there is little doubt that the causes of such differences are varied across the globe. There is some evidence of the greater biological fragility of the male (both genetic and hormonal; see Kraemer, 2000), leading to higher mortality from some of the major killers in the developed world such as circulatory disease (Fazal et al., 2014) and cancers (Payne, 2001). The Marmot review of the social determinants of health (UCL, 2013) suggests several other reasons for these sex differences, including greater levels of occupational risk, greater involvement in unhealthy lifestyle behaviours (smoking, drinking, dietary practices and so on), male norms of risk-­taking (for example, extreme sports, violence, fast driving) and, linked to these male norms, men being more likely to delay seeking help and attending primary care services. Such concerns have also been raised within the Australian male health context (Australian Institute of Health and Welfare, 2011; Smith et al., 2008). We return to some of these issues of ‘masculinity’ and ‘male role norms’ below. So far we have concentrated just on sex differences, yet as has been recognized previously, differences in health status between different groups of men are probably as significant and relevant as differences between men and women. Such ‘between men’ differences have therefore become much more part of discussions and research within the men’s health arena in the last 20 years. A careful examination of aggregated data reveals substantial differences between different categories of men, particularly in relation to socio-­economic status. The category ‘men’ is therefore not a homogenous group. From a public health perspective, it is crucially important to understand gender in the wider socio-­cultural context of men’s lives, and to consider how gender interacts with factors such as social class, education, age, employment status, race, ethnicity, sexual orientation and disability. For example, compared to men in the highest occupational classes, men from the lower occupational classes have poorer health outcomes and experience significantly higher mortality rates for the five major causes of death (White et al., 2011a). Indeed, as socio-­economic circumstances worsen, men’s life expectancy falls dramatically, with the rate of premature death increasing across the spectrum of health conditions. What is particularly noteworthy is that the magnitude of this socio-­economic differential in mortality is greater among men than it is among women, suggesting that men’s death rates appear to be more strongly influenced by socio-­economic factors (White et al., 2011b). The more recent emergence of men’s health at a policy level (Department of Health and Children, 2009; Department of Health and Ageing, 2010a; Ministério da Saúde, Brasil, 2009) situates men’s health within a broad social determinants perspective, and highlights the interaction between gender and social disadvantage as a key determinant in the health outcomes for men. It is difficult, however, to determine the precise causal pathways that contribute to this stepwise gradient that shows an increase in ill-­health and premature death with each step down the social class ladder (Lohan, 2007). Why is the gradient more pronounced in men, and what is it about ‘the clustering of material,

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Public health discourses on men’s health  ­119 cultural and psychosocial factors’ (Lohan, 2007: 496) that appears to be particularly detrimental to the health status of men? For example, when compared with women and men from more affluent backgrounds, men who live in poorer material and social conditions – including unemployed men (Institute of Public Health in Ireland, 2011), ethnic minority men (Fesus et al., 2012; Williams, 2003), prisoners (Binswanger et al. 2007), homeless men (Morrison, 2009) and those with lower educational attainment (Huisman et al., 2005) – are less likely to eat healthily or engage in adequate physical activity, more likely to be overweight or obese, drink excessively, smoke or use illicit drugs, and less likely to engage in routine or preventative health checks. There has been a tendency, one could argue, to accept as inevitable that the adoption of unhealthy lifestyles and risk behaviours is somehow a product of social disadvantage, with little questioning of the causal links between health practices and social disadvantage. For example, evidence from research on the East–West divide in mortality rates among men in Europe (White et al., 2011b) points towards men being less adaptive than women in coping with change – such as more transient and unstable working conditions, increasing unemployment rates and changing family structures (reduction in marriage and increased divorce) – all of which have occurred against a backdrop of widespread political, economic and social upheaval experienced in Eastern Europe in recent decades.

MEN, ‘MASCULINITIES’ AND PUBLIC HEALTH Implicit in many of the discussions on men and public health (and sometimes explicit in such discussions) is the role that ‘masculinity’ – what it is to be a man in society – plays in relation to men’s health practices (their behaviours) and health outcomes. Men are often presented in two different ways in relation to this in these discussions (although they can be simultaneously presented in both of these ways within the same discussion). First, they are presented as a public health problem. The nature of ‘being a man’, one’s masculinity (whether seen as biologically driven or socially derived), means that men create a public health problem for themselves and for others. As we have already indicated earlier in this chapter, men are more likely to engage in negative lifestyle practices (for example, smoking, drinking, drug-­taking, violence, extreme sports, overworking) that are linked to traditional masculine ideals of men as being strong, invulnerable, in control and risk-­takers, to name a few. In addition, these ‘masculine’ behaviours also have public health implications for others who can be directly or indirectly affected by the impact of these actions; for example, female partners who may have to become carers following men’s extreme sports accidents, or the impact of male violence on those who are victims of such acts. This view, in turn, leads some within the public health field to identify men as ‘their own worst enemy’ (Williamson, 1995; Taylor et al., 1998) when it comes to their health and that of others. Linked to this view is the idea that masculinity is also implicated in men’s supposed poor uptake of services: that is, traditional masculine norms of being strong and stoical are said to mitigate against help-­seeking and therefore lead to situations where men are seen as irresponsible in presenting late and consequently suffering worse health outcomes associated with this late presentation (Taylor et al., 1998). Second, men are presented as victims in terms of their health outcomes because of the pressure they are under to live up to expected male roles. The pressure to conform to

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120  Handbook on gender and health gender stereotypes is said to drive men to engage in lifestyle practices which have the inevitable negative consequences on health outcomes. For example, the pressure to achieve and provide in terms of status and finance may lead men from socio-­economically deprived communities to engage in criminal practices (such as drug supplying, gang violence) and men from more affluent communities to work excessively hard to purchase the symbols of such success (the right car, house, holiday and so on). However, not being able to live up to these male gender stereotypes creates feelings of failure – so-­called ‘gender role strain’ (Robertson, 2007: 29) – which also has public health consequences. For example, the centrality of work and the breadwinner role in men’s lives has been said to account for men being more susceptible to work-­related stress (and associated conditions such as cardiovascular disease), but also to mental ill-­health and suicide in times of economic recession and redundancy (Wilkins, 2010: 22; Mind, 2009: 19). In addition, those who take this view of men as public health victims also often point out how health services are mainly feminized and lack the necessary gender-­sensitive approach to facilitate engagement with men. This is then said to account for men’s lower use of services, rather than the view that men take an irresponsible approach to health service engagement (Banks, 2001; Banks and Baker, 2013). We have touched on the issue of men, masculinity and health service use. This is one of the main areas of discussion within the men and public health field and requires a little further consideration here. The commonsense view, often repeated in lay and health professional discourse, is that men use health services less than women and delay seeking help for symptoms for longer than women. However, a great deal of recent work shows that the situation is far more complex than this. There is some evidence from the United Kingdom (UK) and Ireland that men are diagnosed at a later stage for certain cancers (Banks and Baker, 2013; Clarke et al., 2013), yet this does not necessarily mean men present later (that is, there may be other reasons for this diagnosis at a later stage, such as physiological sex differences in cancer progression). Several studies over the last decade coming from the Medical Research Council/Chief Scientist Office (MRC/ SCO) Social and Public Health Sciences unit in Glasgow suggest that sex differences in presentation (apart from the area of mental health and psychosocial concerns) are rarely significant across five major condition types (Hunt et al., 1999): for back pain and headaches (Hunt et al., 2011), for three non-­sex-­specific cancers (Wang et al., 2014) and for general primary care consultations (Wang et al., 2013). This work is further supported by a review of gender-­comparative studies which concluded that men experiencing ill-­health were no less likely to seek help than women (Galdas et al., 2005). What seems to be the case, as we have suggested elsewhere (Robertson and Williams, 2009), is that differences in primary care consultation rates (which are only apparent in the 16–60 years age range) seem much more linked to women’s use of reproductive and female-­specific screening services and differences in consultation for psychosocial concerns, than they are to masculinity-­linked fears of being seen as weak when symptoms present. Indeed, a study in Australia has shown that men actively engage in self-­monitoring their health prior to seeking help (Smith et al., 2008). So far we have spoken of ‘masculinity’ as if it is only a set of individual character traits that men possess to greater or lesser degrees and that are predominantly negative in relation to public health outcomes. This view has led some in the men’s health field to suggest that we dispense with the term and its pejorative connotations, and focus instead on the

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Public health discourses on men’s health  ­121 social determinants of health and on some of the positive (salutogenic) aspects that men offer in promoting their own health and that of others (Macdonald, 2011). In addition, writers such as Lohan (2007) and Robertson and Williams (2012) have highlighted how masculinity should be more fully conceptualized in ways similar to those found within the Critical Studies of Men arena; that is, in ways that recognize that masculinity and gender are about sets of interpersonal relationships that become embedded within social structures in ways that have a significant impact on public health. Such a view enables recognition of how men’s ‘behaviours’ are created within and through particular gendered social contexts. Men live and work in families and communities within complex sets of relationships which can act to restrain, and facilitate, particular lifestyle ‘choices’ (health practices) and it is this social context that generates such practices rather than individual male ‘traits’ (Robertson and Williams, 2007). Robertson and Williams (2012) make a strong case for maintaining a focus on masculinities (providing that this is adequately conceptualized) as a way of more fully ­elucidating how men’s practices impact on (and also are influenced by) social relations in creating and sustaining gendered hierarchies and health inequalities that influence health outcomes for men, women and children. Using the UK as a case example, Williams et  al. (2009) demonstrate how the dominance of biomedical notions that focus on the individual body combine with neoliberal concepts of individual ‘choice’ and psychological models of individual ‘behavioural change’ to create perceptions of public health that neglect the importance of social context, social relationships and social determinants in shaping men’s health experiences. They further suggest that the focus on negative health behaviours on the part of men as a basis for delivering public health services and designing policy is limited, as it eschews wider notions of gender, and the links between masculinities and other structural social and economic factors. What they advise are approaches where there is a political commitment to social and economic policies that promote equity and social justice (for example, redistributive taxation, greater increases in the national minimum wage, increases in benefit levels, policies committed to drive down unemployment and underemployment, investment in affordable good-­ quality housing and childcare) as the most appropriate and effective way to improve the health of men (and, relatedly, that of women and children).

MEN, PUBLIC HEALTH AND THE GLOBAL SOUTH So far this chapter has focused on men and public health in a developed, ‘Global North’ context. In this section we wish to briefly consider what is known about men and public health in the ‘Global South’ and what this offers to the field. The gender inequalities in life expectancy noted at the start of this chapter are also present in the Global South. In countries classified as least or less developed, adult mortality has fallen faster amongst women than amongst men over the last 20 years, and in the region with lowest life expectancy at birth, sub-­Saharan Africa, men are living 5.3 years less than women (Jamison et al., 2013). The impact of social structures (rather than individual behaviours) as factors creating inequitable health outcomes amongst different groups of men (as well as between men and women) has been recognized in the Asian continent context, leading to a call for a public health approach to addressing Asian men’s health needs (Tong and Low, 2012).

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122  Handbook on gender and health In the wake of HIV, and wider concerns about sexual and reproductive health, a significant amount of work has now been undertaken considering the role of masculinity in gender equality and public health in Africa and South America. Across several African countries, adherence to certain aspects of hegemonic masculinity has been associated with increased risk of HIV infection, inhibition in seeking HIV testing, and difficulty dealing with HIV diagnosis (Skovdal et al., 2011) and accessing anti-­retroviral therapy (ART) (Cornell et al., 2011). Much of this epidemiological data has generated interest in how gender and masculinity might be addressed to create better outcomes, not only in HIV rates and treatment but also in other areas of reproductive health and in wider public health issues such as men’s involvement as parents and male violence. Taking a lead from the women’s movement, and emerging from the Bejing Declaration, particular attention has been paid to how taking a gender relations approach and engaging men as partners can lead to a more successful impact across a range of public health issues. Consequently, programmes based on promoting more equitable gender relations, and focusing attention on engaging men as partners in this process, have been implemented across a range of public health contexts in the Global South. These programmes have often been aimed at transforming hegemonic masculinity views and associated practices. For example, the ‘One Man Can’ programme in South Africa (now replicated across other African countries), which seeks to reduce the spread of HIV and reduce male violence, was successful in reconfiguring ideas about hegemonic masculinity and shifting participants’ beliefs and practices regarding relationships, household division of labour and women’s rights (Dworkin et al., 2013). Indeed, a significant piece of work reviewing 58 public health programmes with men and boys, the majority of which were in the developing-­world context (Barker et al., 2010), shows that those incorporating a gender-­transformative approach and promoting gender-­equitable relationships were more effective in producing behaviour change amongst men than those that were gender-­neutral or gender-­sensitive. It would be timely to consider whether inserting gender-­transformative elements into men and public health interventions in the Global North could deliver similar results and help them move beyond the mainly individual behaviour-­oriented interventions that form the current men’s public health arena.

FRAMING MEN’S HEALTH AS AN INTERSECTORAL ENDEAVOUR Viewing men’s health from a social determinants of health perspective means that issues directly relating to gender and identity are critical considerations when aiming to improve men’s health. It demonstrates that levers of action to improve men’s health often sit outside of the health arena. We argue that it is these policy levers which are most likely to influence the ability to reduce the uneven distribution of health outcomes between men, thus reducing inequities experienced by the most marginalized and disadvantaged groups of men. This is particularly pertinent in developing-­world contexts where gendered health and social inequities are commonplace. Two emerging strategies for addressing such inequities include the adoption of a Health in All Policies (HiAP) approach and a gender mainstreaming (GM) approach. We briefly discuss both approaches below.

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Public health discourses on men’s health  ­123 HiAP is a relatively recent innovation reflective of earlier joined-­up public policy approaches where improving population health is considered to be a shared goal across all sectors (Kickbusch and Buckett, 2010). It implies challenging nearly every societal actor, sector and institution at all levels of governance to ‘think health’ and contribute to the circumstances in which people can be healthy (Kickbusch, 2010). HiAP is also perceived to provide an additional level of legitimacy for policy-­makers to incorporate a more explicit equity agenda and to challenge neoliberal policies that privilege growth in economic activity which currently dominate public and policy arenas (Baum and Laris, 2010). Gender mainstreaming, on the other hand, is about promoting gender equality (and more notably equity) in policy and practice spheres (Walby, 2005). It aims to make visible the gendered nature of assumptions, processes and outcomes (Walby, 2005). Gender mainstreaming has historically emerged out of a feminist discourse examining inequities between men and women ­(Woodford-­Berger, 2004). Within a health context, gender mainstreaming is now considered as the most effective strategy to achieve gender equity (European Institute of Women’s Health, 2001; CSDH, 2008). This is a strategy that promotes the integration of gender  ­concerns into the ­formulation, monitoring and analysis of policies, programmes and projects, with the objective of ensuring that women and men achieve the highest health status (European Institute of Women’s Health, 2001; Richardson, 2004; CSDH, 2008). We consider that combining Health in All Policies (HiAP) and gender mainstreaming approaches is one plausible way of improving the global men’s health policy landscape. Common features include a horizontal influence across various public policy discourses; an explicit focus on reducing health and social inequities (most notably those relating to gender); and a requirement of intersectoral action. By framing men’s health as an issue within education, the economy, housing, transport, disability and employment policy contexts (among others), a new way of tackling problems emerges. Likewise, by setting a mandate for working together across sectors by positively influencing the conditions and environments in which men live, work and play, the likelihood of achieving improved men’s health outcomes is significantly heightened. For example, improved public policy relating to employment conditions, such as the provision of paternity leave, conditions relating to minimum wages, or maximum hours to be worked in a week, can have a profound effect on the physical, mental and emotional health and well-­being of men (and their families). One can argue that greater health benefits can be accrued when dovetailed with gender-­specific health policies such as workplace health programmes delivered in labour-­intensive male-­dominated workplaces; or flexible work arrangements supporting men to access health care during usual working hours. While joined-­up public policy approaches are preferred, these seldom occur. To date there have been minimal policy inroads in this regard. In some instances the development of sex-­specific national men’s health policies has provided an opportunity to progress the adoption of HiAP and/or gender mainstreaming approaches, most notably in Ireland and Australia. But this has not necessarily been the driving strategy or primary focus for policy development or implementation in these countries to date. We now draw on two examples (limited by their Western focus) to describe the approaches adopted in Ireland and Australia whilst transitioning from phases of men’s health policy development to implementation.

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124  Handbook on gender and health

MEN’S HEALTH POLICY DEVELOPMENT AND IMPLEMENTATION It is only in relatively recent times that men have been identified as a specific population group for the strategic planning of health, with the emergence of policy responses in countries such as Ireland (Department of Health and Children, 2009), Australia (Department of Health and Ageing, 2009) and Brazil (Ministério da Saúde, Brasil, 2009). In citing the wide-r­anging psychological, social and economic consequences of premature mortality among men in Europe, White et al. (2011b: 343) note how men are conspicuous by their absence at a health policy level: ‘in both national and European health policy, “men” and “masculinity” are largely taken for granted, a neglect that has severely limited the capacity to develop evidence-­based programmes that meet their health needs’. This section will consider the experiences of men’s health policy development in Ireland and Australia within what frequently emerges as a controversial aspect of current debates relating to men and public health responses. The impetus and background to policy development as well as the key milestones achieved to date will be briefly considered. There will be a particular focus on reflecting on what lessons have been learnt in transitioning from policy development to implementation in these countries (Richardson and Carroll, 2009; Smith et al., 2009a; Smith et al., 2010; Richardson and Smith, 2011; Richardson, 2013). The impetus for policy action in both countries can be traced to a number of factors. Whilst sex differences in life expectancy and mortality may have provided the initial leverage for policy action in men’s health, the process of men’s health policy development in Ireland and Australia was grounded in a recognition of diversity within the category ‘men’ with due regard, in particular, to the social determinants of men’s health; an explicit recognition (within an Irish context in particular) of the need for a gendered approach to men’s health; and a wider grassroots development within men’s health at a research, advocacy, and community or voluntary level (Richardson and Smith, 2011). Policy Context in Ireland The impetus and mandate for the development of Ireland’s National Men’s Health Policy (NMHP) can be traced to a commitment set out in Ireland’s National Health Strategy at that time (Department of Health and Children, 2001: 163), to ‘develop a policy for men’s health and health promotion’. This prompted the Department of Health and Children in Ireland to commission a three-­year men’s health research project to specifically inform the development of the policy. Following publication of this research report (Richardson, 2004), an expert Men’s Health Steering Group was convened to oversee the development of the policy, which included an extensive consultation process and a review of the international literature on men’s health. A draft policy document was presented to key stakeholders (including other government departments) to reach final consensus on the wording of the policy recommendations and actions. A National Implementation Group (NIG)2 has been tasked with overseeing and monitoring the implementation of the policy. The NIG is also strongly represented in a Gender Mainstreaming Group within the Health Service Executive in Ireland. The policy is currently the subject of an external review following the end of its five-­year time frame.

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Public health discourses on men’s health  ­125 Whilst the theoretical and philosophical principles underpinning the policy and the key policy recommendations and actions have been documented elsewhere (Richardson and Carroll, 2009; Richardson and Smith, 2011), in summary, the policy: seeks to develop men’s health in synergy with other government departments and across different sectors; adopts a gendered and gender-­relations approach; recognizes differences between men; adopts a social determinants and community development approach to those subgroups of men most in need; targets an upstream preventative and health promotion approach; embraces a strengths perspective; and seeks to encourage men to take increased ownership of and responsibility for their own health. Policy Context in Australia There has been a long-­standing interest in men’s health policy development across Australia (Butler, 1996; Schofield, 2004). At the national level this has included the development of a draft men’s health policy (Butler 1996), the commissioning of a men’s health research agenda (Connell et al., 1998) and the development of a national framework for improving the health of Aboriginal and Torres Strait Islander males (Aboriginal and Torres Strait Islander Male Health and Wellbeing Reference Committee Working Party, 2004). Strategic state-­based policy development has also been advanced in New South Wales, South Australia and Victoria (NSW Health Department, 1998, 1999; DHS, 2000; Hayes, 2001; NSW Department of Health, 2003; Bentley, 2007; SA Health, 2008; Brown and Macdonald, 2009; NSW Department of Health, 2009; Department of Health, 2010). This created a precedent in relation to addressing men’s health needs from a policy standpoint. Yet, men’s health really remained only at the periphery of national health policy discussions. This changed in June 2008 when the newly elected Labor government announced its intention to develop Australia’s first ever national men’s health policy (which was later released as the national male health policy) (Roxon, 2008). ‘Developing a men’s health policy: setting the scene’ was released at this time (Department of Health and Ageing, 2008a). In November 2008, two additional companion documents were also released (Department of Health and Ageing, 2008b; Department of Health and Ageing, 2008c). The Australian government also appointed a number of National Men’s Health Ambassadors and led a large-­scale public consultation process (Smith and Bollen, 2009; Department of Health and Ageing, 2010a). Recognizing and responding to health inequities through action on the social determinants of health was considered a ‘hot topic’ throughout this consultation process and parallelled a wider global discourse on social determinants of health, which coincided with the release of the final report of the World Health Organization (WHO) Commission on Social Determinants of Health at that time (CSDH, 2008; Smith and Bollen, 2009). In our view, this dialogue and subsequent ‘policy window’ was critically important for the way in which the national male health policy was subsequently framed. In addition to the abovementioned NMHP development process, a Senate Select Committee on Men’s Health (SSCMH) was also established in November 2008 to examine a range of issues relating to services that support men’s health (Parliament of the Commonwealth of Australia – Senate, 2008; SSCMH, 2009). In parallel, the announcement of the NMHP coincided with the development of the National Preventive Health Strategy (NPHT, 2009) and subsequent investments. This created

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126  Handbook on gender and health a flurry of excitement and a sense of optimism about health promotion in Australia (Oldenburg and Harper, 2008; Smith et al., 2009b). It also provided a unique opportunity to ensure that the men’s health policy agenda had a strong health promotion and prevention focus, akin to that of Ireland’s NMHP. In May 2010, close to a year after the initial consultation process had finished, Australia’s first ever NMHP – ‘building on the strengths of Australian males’ – was released. Concepts relating to masculinities were strikingly absent from the Australian NMHP, which marked a significant shift away from the equivalent gender mainstreaming commitment reflected in Ireland’s NMHP (Saunders and Peerson, 2009). Whilst the policy scope was comprehensive, the mandate for implementation was somewhat sketchy, with many of the funding commitments relating to existing government commitments. Key Milestones to Date Richardson (2013) documents the key milestones to date in the context of Ireland’s NMHP. Amongst the key positive outcomes are the strong governance and accountability structures and procedures that are now in place for men’s health; the exponential rise in research and evaluation reports that have contributed to a growing evidence base for men’s health; the implementation of a comprehensive national men’s health training programme; the development of a range of men’s health information resources targeted at men in different settings; the emergence of some promising workplace-­based men’s health promotion initiatives; the expansion of community-­based men’s health initiatives targeted at vulnerable groups of men; and the emergence of the position of the Men’s Health Forum in Ireland as the leading men’s health advocacy organization and coordinating body for Men’s Health Week. Less work has been completed in relation to milestones achieved with respect to Australia’s male health policy, which emphasizes the importance of and need for investing in robust evaluation and monitoring frameworks when implementing policies, such as the NMHP. However, some useful work relating to the structure and influence of men’s health policy networks has been undertaken (Holden and Lin, 2011). Challenges in Transitioning from Policy Development to Implementation: Key Lessons Learnt to Date A number of challenges and key learning points have been identified from both countries in transitioning from policy development to implementation (Richardson and Smith, 2011; Richardson, 2013). From the point of view of timing, Ireland’s NMHP missed the boat in terms of garnering significant ring-­fenced funding to implement the policy Action Plan. The policy launch coincided with the economic downturn and a subsequent contraction and rationalization of available resources. Nevertheless, a number of significant milestones have been achieved. One of the key markers of successful policy is integration with existing policy and, within an Irish context, the publication of the NMHP has been the catalyst for increased men’s health activity in other areas (for example, health promotion, occupational and workplace health, community development projects). Likewise, there was minimal ring-­fenced funding made available to support the implementation of the Australian NMHP. Funding that was made available has reflected minor, but

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Public health discourses on men’s health  ­127 critical investments. These include the establishment of an Australian Longitudinal Study on Male Health (ALSMH), a commitment for the Australian Institute of Health and Welfare to produce male health bulletins, and investment of $16.7 million into dedicated male health programmes, including support for Men’s Sheds (see, for example, Wilson et al., 2015) and the development of resources such as a Do-­It-­Yourself Health Toolbox. There are limitations in relation to the way in which these activities have been implemented, such as the exclusion of remote and rural men from the ALSMH, and the disregarding of global evidence about men’s health promotion and masculinities (Smith, 2007; Smith and Robertson, 2008; Robertson et al., 2009; Fleming et al., 2014). However, it is important to celebrate the incremental wins that will be of long-­standing benefit to men’s health. Despite an exponential growth in men’s health work in both countries over recent years, there is still a huge void between the breadth of policy action called for in both NMHPs and the number of dedicated practitioners working in the area of men’s health. Whilst Ireland’s NMHP called for appropriate structures with regard to implementation at an interdepartmental (Department of Health and Children, 2009: 44) level, these did not materialize, resulting in a lack of governance structure to deal with cross-­ departmental planning. In this regard, men’s health is no different to other policy areas that seek to garner cross-­departmental support in terms of the struggles associated with leadership, accountability and governance issues. Indeed, this is a good example of the very real challenges of applying Health in All Policies (HiAP) in practice. In Australia, much of the workforce used to progress the implementation of the NMHP was drawn from a public health or primary health care background. This workforce has been particularly threatened by systematic disinvestment by state and national governments over the past few years (see, for example, Smith et al., 2016), thus reducing the ability to implement actions described in the NMHP. One of the key aspects of governance with respect to Ireland’s NMHP implementation  has been the alignment of the policy with a broader gender-­mainstreaming framework (GMF) within the health services (Health Service Executive, 2012). This is in keeping with the NMHP’s call for the positioning of men’s health ‘within a mainstreamed equality agenda with a gender focus’ (Department of Health and Children, 2009: 20). Crucially, having a NMHP provided a blueprint for policy action on men’s health that informed the GMF and ensured that men’s health experts3 contributed to the development of the GMF, thus overcoming previously defined difficulties with GM as being synonymous with women’s health (Bates et al., 2009). Indeed, this can also be seen in practice by way of ongoing work in the development of GM toolkits and GM pilot projects which are being informed by both men’s and women’s health experts and practitioners. The positioning of men’s health within a GMF is also important for two very practical reasons. One of the key markers of successful policy is integration with existing policy (Bull et al., 2004). A key function of the NMHP has been to apply a gender lens to existing and emerging policy areas. The NMHP is also increasingly being cited in funding applications from a broad cross-­section of organizations, which also demonstrates the cross-­fertilization of the NMHP into other policy areas. Secondly, with the contraction and rationalization of available resources and very limited ring-­ fenced funding, the potential of a new (men’s health) policy to compete for a shrinking pot of public sector funds was also going to be limited. Similarly, in Australia, policy

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128  Handbook on gender and health c­ ommitments that framed the NMHP implementation agenda were reflective of commitments the Australian government had already made in other public policy contexts. While this ensured policy alignment, a limiting factor of this approach was that there was little additional ring-­fenced funding allocated for the implementation of the NMHP. Indeed, the social determinants of health focus had by nature provided the Australian government with a strategy to embed a ‘whole-­of-­government’ or HiAP approach on paper, that did not really require a great deal of additional investment. Rather, the Australian government was able to cleverly highlight work happening in other sectors, or existing activity in the health sector, via case studies and recent budget commitments to demonstrate the way in which it was already contributing to the health and well-­being of men in Australia. One of the key challenges in conducting in-­depth consultation processes for both policies has been to manage the expectation that emanates from those who make inputs to the process and to ensure that there is transparency in signposting the choices that are made in policy decision-­making. This also raises the question of ‘competing needs’ (Bull et al., 2004) and making difficult choices in terms of prioritizing certain policy issues over others and managing expectations of different interest groups. Whilst many such choices were made in the context of Ireland’s NMHP (Richardson and Smith, 2011), nevertheless the scope and breadth of the final policy document was, to say the least, ambitious; especially in light of the policy launch coinciding with recession and financial crisis. With hindsight, there may have been merit in scaling back the scope and breadth of Ireland’s NMHP Action Plan to more realistic proportions. An alternative might have been to time-­frame priorities within the Action Plan, thereby setting out wider boundaries as part of a vision for ‘men’s health’ but acknowledging that a longer time frame would be needed to make inroads on all areas. Notwithstanding the limitations of the approach taken, the NMHP document does provide a very worthwhile template for ongoing and future GM and HiAP approaches. Perhaps the biggest challenge in the transition to policy implementation in both countries has been to continue to get buy-­in across government departments on policy implementation. Perseverance and patience were the cornerstones in developing Ireland’s NMHP (Richardson and Carroll, 2009) and underpin ongoing efforts in the transition to policy implementation in both countries. The experience of both countries is that governance and accountability are critically important to effective policy implementation. The inclusion of a time-­framed Action Plan (with a ‘Lead Agency’ identified for each Action) in tandem has made the issue of accountability explicit within Ireland’s NMHP. As highlighted earlier, this has been further enhanced by the appointment of an NIG to oversee the implementation of the Ireland NMHP policy; policy evaluation is essentially embedded in the policy and has begun immediately. This has been less evident within the Australian NMHP context. While an overarching NMHP Advisory Group was established with high-­profile men’s health experts, little is known or documented about how often it met and what level of decision-­making capacity it was afforded. What has been established is that the men’s health sector in Australia consists of large, loosely coupled (moderate-­to low-­density) networks that lack defined hierarchical or centralized structures (Holden and Lin, 2011). Paying greater attention to such networks and their respective impact on policy governance within the context of the implementation of the NMHP is warranted.

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Public health discourses on men’s health  ­129 Finally, one of the key challenges of any new policy initiative is to profile successes and to build momentum. Both the Irish and Australian NMHPs have an explicit strengths-­ based approach. In both cases it will be important to document further successes with a focus on effectiveness and efficacy carefully built into evaluation processes. An important challenge for both NMHPs is to quantify the likely dividends realized by targeting men’s health at a policy level, including at an overall population level and at an economic and environmental level. From a gender relations perspective, the impact and potential benefits that can accrue from an NMHP for women and children also need to be carefully documented.

CONCLUSION Addressing the issue of high levels of premature mortality amongst men remains a significant public health concern across much of the globe. Appropriate public health responses need to take account of significant health inequalities across geographical areas and regions, and across different groups of men in relation to social class, ethnicity, sexuality and other demographic factors. This chapter has demonstrated that addressing men’s health is a highly complex and multifaceted public health issue and one that needs to move well beyond individual behaviour change approaches. We have shown that national and global programme and policy responses relating to men’s health need to consider gender (specifically, masculinities) in concert with other social and cultural considerations that shape identity, in order to be most effective. The publication of NMHPs in Ireland and Australia represents a significant landmark in the ongoing evolution of the field of men’s health. In considering both structural and individual-­level influences, these policies provide a clear blueprint and useful contextual evidence base for tackling men’s health in each country. The approaches to policy development and methodologies used provide a useful roadmap for men’s health policy development in other countries and can, perhaps, leverage support for an increased policy focus on men’s health outside of Ireland and Australia.

NOTES 1. These included the Department of Social and Family Affairs, Department of Education and Science, Department of Enterprise, Trade and Employment and Department of Justice, Equality and Law Reform. 2. This group comprises members from the Department of Health and Children, the Health Service Executive, the Institute of Public Health in Ireland, the Irish Cancer Society, the Irish Heart Foundation, the Men’s Health Forum in Ireland, the Men’s Development Network and two academic institutions. 3. Representatives from the NMHP Implementation Group, the Men’s Health Forum in Ireland and the Men’s Development Network were part of the GMF Steering Group.

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Public health discourses on men’s health  ­131 Dworkin, S.L., Hatcher, A.M., Colvin, C. and Peacock, D. (2013). Impact of a gender-­transformative HIV and anti-­violence program on gender ideologies and masculinities in two rural South African Communities. Men and Masculinities 16(2): 181–202. European Commission (2011). The first state of men’s health in Europe report. Luxembourg: European Commission. European Institute of Women’s Health (2001). Newsletter 2001(3), www.eurohealth.ie/cancom/eiwh.htm Fazal, F., Azibani, F., Vodovar, N., Cohen Solal, A., Delcayre, C. and Samuel, J.L. (2014). Impact of biological sex on the pathophysiology of the heart. British Journal of Pharmacology 171(3): 555–566. Fesus, G., Ostlin, P., McKee, M. and Adany, R. (2012). Policies to improve the health and well-­being of Roma people: the European experience. Health Policy 2012 (105): 25–32. Fleming, P., Lee, J. and Dworkin, S. (2014). ‘Real men don’t’: constructions of masculinity and inadvertent harm in public health interventions. American Journal of Public Health 104(6), 1029–1035. Galdas, P., Cheater, F. and Marshall, P. (2005). Men and health helpseeking behaviour: literature review. Journal of Advanced Nursing 49(6): 616–623. Hayes, R. (2001). Men’s Health Promotion: Developing an Intersectoral Strategic Framework. Volume 2. Carlton South: Victorian Health Promotion Foundation. Health Service Executive (2012). A framework for integrating gender equality in health service executive policy, planning and service delivery. Health Service Executive, Ireland. Holden, C. and Lin, V. (2011). Network structures and their relevance to the policy cycle: a case study of the National Male Health Policy in Australia. Social Science and Medicine 74(2), 228–235. Horton, R. (2012). GBD 2010: understanding disease, injury and risk. Lancet 380 (9859): 2053–2054. Huisman, M., Kunst, A.E., Bopp, M., et al. (2005). Educational inequalities in cause-­specific mortality in middle-­aged and older men and women in eight Western European populations. Lancet 365: 493–500. Hunt, K., Adamson, J. and Hewitt, C. (2011). Do women consult more than men? A review of gender and consultation for back pain and headache. Journal of Health Services Research and Policy 16: 108–117. Hunt, K., Ford, G., Harkins, L. and Wyke, S. (1999). Are women more ready to consult than men? Gender differences in family practitioner consultation for common chronic conditions. Journal of Health Services Research and Policy 4(2): 96–100. Institute of Public Health in Ireland (2011). Facing the challenge: the impact of recession and unemployment on men’s health in Ireland. Dublin: Institute of Public Health in Ireland. Jamison, D.T., Summers, L.H., Alleyne, G., Arrow, K.J., Berkley, S. and Binagwaho, A. (2013). Global Health 2035: a world converging within a generation. Lancet 382: 1898–1955. Kickbusch, I. (2010). Health in All Policies: the evolution of the concept of horizontal health governance. In: Kickbusch, I. and Buckett, K. (eds), Implementing Health in All Policies: Adelaide 2010. Adelaide: Government of South Australia. Kickbusch, I. and Buckett, K. (2010). Implementing Health in All Policies: Adelaide 2010. Adelaide: Government of South Australia. Kraemer, S. (2000). The fragile male. British Medical Journal 321: 1609–1612. Lohan, M. (2007). How might we understand men’s health better? Integrating explanations from critical studies on men and inequalities in health. Social Science and Medicine 65(3): 493–504. Macdonald, J. (2011). Building on the strengths of Australian males. International Journal of Men’s Health 10(1): 82–96. Mind (2009). Men and Mental Health: Get it Off Your Chest. London: Mind. Ministério da Saúde, Brasil (2009). Gabinete do Ministro. Portaria No. 1.944. Institui no âmbito do Sistema Único de Saúde (SUS), a Política Nacional de Atenção Integral à Saúde do Homem. Diário Oficial da União. Morrison, D.S. (2009). Homelessness as an independent risk factor for mortality: results from a retrospective cohort study. International Journal of Epidemiology 38: 877–83. National Preventative Health Taskforce (NPHT) (2009). Australia: The Healthiest Country by 2020 – National Preventative Health Strategy Overview. Canberra: Commonwealth of Australia. NSW Department of Health (2003). Aboriginal Men’s Health Implementation Plan. North Sydney: NSW Department of Health. NSW Department of Health (2009). NSW Men’s Health Plan 2009–2012. North Sydney: NSW Department of Health. NSW Health Department (1998). Strategic directions in men’s health: a discussion paper. North Sydney: NSW Health. NSW Health Department (1999). Moving forward in men’s health. Gladesville: NSW Health. Oldenburg, B. and Harper, T. (2008). Investing in the future: prevention a priority at last. Medical Journal of Australia 189(5): 267–268. Oliffe, J.L., Robertson, S., Blye, F., McCreary, D.R., Tremblay, G. and Goldenberg, S.L. (2010). Men’s health in Canada: a 2010 update. Journal of Men’s Health 7: 189–192.

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132  Handbook on gender and health Parliament of the Commonwealth of Australia – Senate (2008). Terms of reference of the Senate Select Committee on Men’s Health. Journals of the Senate 44, 13 November. Payne, S. (2001). ‘Smoke like a man, die like a man’? 1: A review of the relationship between gender, sex and lung cancer. Social Science and Medicine 53: 1067–1080. Richardson, N. (2004). Getting inside men’s health. Kilkenny, Ireland: Health Promotion Department, South Eastern Health Board. Richardson, N. (2013). Building momentum, gaining traction: Ireland’s National Men’s Health Policy – 5 years on. New Male Studies 2(3): 93–103. Richardson, N. and Carroll, P. (2009). Getting men’s health onto a policy agenda – charting the development of a national men’s health policy in Ireland. Journal of Men’s Health 6(2): 105–113. Richardson, N. and Smith, J. (2011). National men’s health policies in Ireland and Australia: what are the challenges associated with transitioning from development to implementation?. Public Health 125(7): 424–432. Robertson, S. (2007). Understanding Men and Health: Masculinities, Identity and Well-­being. Maidenhead: Open University Press. Robertson, S., Galdas, P., McCreary, D., Oliffe, J. and Tremblay, G. (2009). Men’s health promotion in Canada: current context and future direction. Health Education Journal 68(4): 266–272. Robertson, S. and Williams, R. (2007). Masculinities, men and public health policy. International Journal of Interdisciplinary Social Sciences 2(2): 361–368. Robertson, S. and Williams, R. (2009). Men: showing willing. Community Practitioner 82(4): 34–35. Robertson, S. and Williams, R. (2012). The importance of retaining a focus on masculinities in future studies on men and health. In: Tremblay, G. and Bernard, F. (eds), Future Perspectives for Intervention, Policy and Research on Men and Masculinities: An International Forum. Harriman, TN: Men’s Studies Press. Roxon, N. (2008). First ever national men’s health policy. Media Release of the Minister for Health and Ageing, 8 June. SA Health (2008). South Australian Men’s Health Strategic Framework 2008–2012. Government of South Australia. Adelaide, South Australia. Salomon, J.A., Wang, H., Freeman, M.K., Vos, T., Flaxman, A.D., Lopez, A.D. and Murray, C.J.L. (2012). Healthy life expectancy for 187 countries, 1990–2010: a systematic analysis for the Global Burden Disease Study 2010. Lancet 380(9859): 2144 –2162. Saunders, M. and Peerson, A. (2009). Australia’s National Men’s Health Policy: Masculinity matters. Health Promotion Journal of Australia 20(2): 92–97. Schofield, T. (2004). Boutique health: gender and equity in health policy. Australian Health Policy Institute. Commissioned paper series 2004/08, University of Sydney. Senate Select Committee on Men’s Health (SSCMH) (2009). Senate Committee Report: Men’s Health – May 2009. Canberra: Senate Printing Unit. Skovdal, M., Campbell, C., Madanhire, C., Mupambireyi, Z., Nyamukapa, C. and Gregson, S. (2011). Masculinity as a barrier to men’s use of HIV services in Zimbabwe. Global Health 7: 13. Smith, J. (2007). Beyond masculine stereotypes: Moving men’s health promotion forward in Australia. Health Promotion Journal of Australia 18(1): 20–25. Smith, J. and Bollen, C. (2009). A focus on health promotion and prevention through the development of a national men’s health policy. Health Promotion Journal of Australia 20(2): 98–101. Smith, J., Braunack-­Mayer, A., Wittert, G. and Warin, M. (2008). ‘It’s sort of like being a detective’: understanding how men self-­monitor their health prior to seeking help and using health services. BMC Health Services Research 8(56). doi: 10.1186/1472-­6963-­8-­56. Smith, J., Crawford, G. and Signal, L. (2016). The case of national health promotion policy in Australia: where to now?. Health Promotion Journal of Australia. Smith, J., Gleeson, S., White, I., Judd, J., Jones-­Roberts, A., Hanzar, T., Sparks, M., Shilton, T. and Shand, M. (2009a). Health promotion: essential to a national preventative health strategy. Health Promotion Journal of Australia 20(1): 5–6. Smith, J. and Robertson, S. (2008). Men’s health promotion: A new frontier in Australia and the UK? Health Promotion International 23(3): 283–289. Smith, J., Robertson, S. and Richardson, N. (2010). Understanding gender equity in the context of men’s health policy development. Health Promotion Journal of Australia 21(1): 76–77. Smith, J., White, A., Richardson, N. and Robertson, S. (2009b). The men’s health policy contexts in Australia, the UK and Ireland: Advancement or abandonment? Critical Public Health 9 (3–4): 427–440. Tong, S.F. and Low, W.Y. (2012). Public health strategies to address Asian men’s health needs. Asia-­Pacific Journal of Public Health 24(4): 543–555. Taylor, C., Stewart, A. and Parker, R. (1998). ‘Machismo’ as a barrier to health promotion in Australian males. In: Laws, T. (ed.), Promoting Men’s Health: An Essential Text Book for Nurses. Ascot Vale: Ausmed Publications. UCL Institute of Health Equity (2013). Review of social determinants and the health divide in the WHO

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Public health discourses on men’s health  ­133 European Region: final report. Copenhagen: World Health Organization, Regional Office for Europe. Available from: http://www.instituteofhealthequity.org/projects/who-­ european-­ review (accessed 9 August 2014). Walby, S. (2005). Gender mainstreaming: productive tensions in theory and practice. Social Politics 12(3): 321–343. Wang, Y, Freemantle, N., Nazareth, I. and Hunt, K. (2014). Gender differences in survival and the use of primary care prior to diagnosis of three cancers: an analysis of routinely collected UK general practice data. PLOS ONE 9(7): e101562. doi:10.1371/journal.pone.0101562. Wang, Y., Hunt, K., Nazareth, I., et al. (2013). Do men consult less than women? An analysis of routinely collected UK general practice data. BMJ Open 3: e003320. doi:10.1136/bmjopen-­2013-­003320. White A. (2008). Men and the problems of late diagnosis. In: Heidelbaugh, J.J. (ed.), Clinical Men’s Health: Evidence in Practice. Philadelphia, PA: Elsevier. White, A., De Sousa, B., De Visser, R., Hogston, R., Madsen, S.A., Makara, P., McKee, M., Raine, G., Richardson, N., Clarke, N. and Zatoński, W. (2011a). Men’s health in Europe. Journal of Men’s Health 8(3): 192–201. White A., de Sousa, B., De Visser, R., Madsen, S.A., Makara, P., Richardson, N. and Zatonski, W. (2013). Europe’s ‘missing men’; the impact of life expectancy improvements on men’s premature mortality. Journal of Epidemiology and Community Health 10 (1093): 1–7. White, A., McKee, M., Richardson, N., De Visser, R., Madsen, S.A., de Sousa, B., Makara, P. and Zatonski, W. (2011b). Europe’s men need their own health strategy. BMJ 343: d7397-­11. Wilkins, D. (2010). Untold problems: a review of the essential issues in the mental health of men and boys. London: Men’s Health Forum. Williams, D. (2003). The health of men: structured inequalities and opportunities. American Journal of Public Health 93(5): 724–731. Williams, R., Robertson, S. and Hewison, A. (2009). Masculinity, ‘men’s health’ and policy: the contradictions in public health. Critical Public Health 19(3): 475–488. Williamson, P. (1995). Their own worst enemy. Nursing Times 91(48): 25–27. Wilson, N., Cordier, R., Doma, K., Misan, G. and Vaz, S. (2015). Men’s Sheds function and philosophy: towards a framework for future research and men’s health promotion. Health Promotion Journal of Australia 26(2): 133–141. Woodford-­Berger, P. (2004). Gender mainstreaming: what is it (about) and should we continue doing it? Institute of Development Studies Bulletin 35(4): 65–72.

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8.  Men, ‘masculinity’ and mental health: critical reflections

Brendan Gough, Steve Robertson and Mark Robinson

MEN’S HEALTH AND MASCULINITIES It is well established that men tend to die younger than women, and there is some evidence that there are more men than women suffering from major diseases, including non-­gendered cancers, heart conditions and diabetes, (European Commission, 2011), although there is some debate about sex differences in morbidity (see Gough and Robertson, 2009). Although it is widely assumed that men do not use health services as much as women, again the situation is complex. What we do know is that men tend to access general practitioner (GP) surgeries less frequently than women, although some groups of men do value early medical advice (see Galdas et al., 2007). Once diagnosed, men often manage their conditions well (see Robertson and Williams, 2009). In the field of mental health, men are more reluctant to seek professional help, and those who do access services often do so only when experiencing a crisis (for example, Addis and Mahalik, 2003; Cochrane and Rabinowitz, 2000). Compared to women, men are also more likely to engage in ‘unhealthy behaviours’ such as binge drinking, and to experience accidents and injury (Courtenay, 2000). Because these patterns around sex and mortality and morbidity cannot be reduced to biology, explanations have focused on gender socialization and, in particular, on ­‘masculinity’. Indeed, early work implicated the ‘male sex role’ in men’s poor health (Harrison, 1978) – but how is masculinity defined? Traditionally, sex role theory has been used to describe and explain how men (and women) behave within Western countries. For example, the work of Brannon (1976) reduced masculinity in the USA to four key traits: ●

‘No Sissy Stuff’: men must avoid any behaviour or characteristic associated with women or femininity. ● ‘Be a Big Wheel’: masculinity is measured by success, power and the admiration of others. ● ‘Be a Sturdy Oak’: manliness is predicated on rationality, toughness and self-­reliance. ● ‘Give ’em Hell’: men must balance the ‘rationality’ of the sturdy oak with daring and aggression, and must be willing to take risks in order to become the big wheel. Psychologists working in the USA have developed various scales purporting to measure masculinity and femininity. For example, the pioneering work of Sandra Bem produced the Bem Sex Role Inventory (BSRI; see Bem, 1974) which treated masculinity and femininity as independent dimensions; in other words, any individual, male or female, could score on both masculinity and femininity scales, and those who scored highly on both were of course labelled ‘androgynous’. Other scales followed in the 1980s 134 Jasmine Gideon - 9781784710859 Downloaded from Elgar Online at 11/03/2017 02:47:53AM via Sydney University

Men, ‘masculinity’ and mental health  ­135 and 1990s, including the Gender Role Conflict Scale (GRCS; see O’Neill, 2008) which set out to measure the extent to which men were stressed in attempting to live up to normative masculine ideals such as those outlined by Brannon (1976). In the USA in particular, the GRC paradigm has been dominant in work on masculinity studies in general and men’s health in particular; one clear finding is that trying to live up to traditional masculinity ideals can be stressful and health-­defeating (O’Neill, 2008). Beyond psychology, sex role theory and related constructs (for example, GRC) are less prevalent. In fact, sex role theory has been widely critiqued for reducing masculinity to a few (measureable) core traits which govern the lives of all men (for example, Connell, 1995). In the interdisciplinary field of ‘Critical Studies of Men and Masculinity’, an explicitly social constructionist approach has prevailed which considers what men do in practice and how this impacts on (and is influenced by) self, others and society. The most influential concept in this literature is ‘hegemonic masculinity’ (Carrigan et al., 1985; Connell, 1995). Hegemonic masculinity concerns the gender order more generally; it is not (only) about men and/or masculinity, but encompasses gender identities, relations and conflicts. As originally formulated, it referred to ‘the currently most honoured way of being a man, it required all other men to position themselves in relation to it, and it ideologically legitimated the global subordination of women to men’ (Connell and Messerschmidt, 2005: 832). A pluralistic perspective is presented where multiple masculinities (and femininities) exist and operate in relation to each other. Specifically, Connell highlighted the operation of power through masculinities, defined as ‘configurations of practice’; at a given moment in a given context some men will enact and be privileged by locally ‘hegemonic’ masculinities, while women and other men will be marginalized or subordinated. Opposition to and oppression of women and gay men are built into hegemonic masculinities. Marginalized men include disabled men, who may have little access to valued masculinities, while subordinated men include gay men, who may be oppressed by heterosexism and homophobia and judged to fall short of ‘masculine’ standards. Discrimination, prejudice and oppression faced by disempowered, alienated men will inevitably impact on health, and we know that, for example, the health of economically disadvantaged men, black and ethnic minority men and gay men tends to be worse than more privileged groups of men (Griffith et al., 2011). Increasingly, masculinity scholars are examining the plight of men situated in the Global South (see Connell, 2009), and we know that in countries classified as ‘least’ or ‘less’ developed, mortality rates have fallen more among women compared to men; and in the region with the lowest life expectancy at birth, sub-­Saharan Africa, men are living over five years less than women (Jamison et al., 2013). Thus we must look beyond masculinity to consider intersections of class, ethnicity, sexual orientation, world region and so on, in order to explain the health of particular groups of men. However, we must not assume that certain groups are always dominant or disempowered; any individual man will experience a range of situations and relationships and in some contexts will take up more powerful positions at certain times, then be placed in subordinated or marginalized positions at others. For example, a manager may assume more power within an organization compared to a porter but this could be reversed in other circumstances (for example, drinking or sporting scenarios). So individuals may embody aspects of hegemonic masculinity in a particular setting, but may nonetheless be relatively

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136  Handbook on gender and health ­ isempowered through their positioning in other social categories and structures. Thus d there may well be material constraints influencing a man’s capacity to occupy hegemonic status, and the embedding of gender within social structures is also very significant here (Robertson and Williams, 2012). Connell also makes the point that many men may be ‘complicit’ with hegemonic ­masculinities: that is, they embody key features while not actively promoting or consciously enacting them. Here Connell (1995: 41) also uses the term ‘patriarchal dividend’, suggesting how they nevertheless benefit from these norms. So Connell’s theory of masculinity is relational as it concerns social comparisons, relative status and competition. Central to Connell’s approach is relations between men and women, since forms of masculinity impact on women as well as men. For example, if masculinity has been defined around paid work outside the home (the traditional breadwinner role) then women have been positioned within the household and responsible for childcare and domestic labour. Nonetheless, another feature of hegemonic masculinity is fluidity: what counts as hegemonic in one time or setting can and does vary, and there may be tensions and conflicts between different masculinities in competition for hegemonic status. For example, for increasing numbers of men an investment in appearance is important and beneficial in an image-­conscious consumer society (for example, for success at work, in relationships, for well-­being) and all manner of grooming and beauty practices may be marshalled, activities unthinkable even a generation ago (moisturising, self-­tanning, applying cosmetics; see Gough et al., 2014). So changing societal norms will mean that men may well have to be vigilant and responsive to change in order to secure and hold on to a hegemonic position. Some theorists highlight the flexibility of contemporary masculinities within Western societies, whereby men can deploy, rework and resist specific masculinities as appropriate, such that ‘masculinity’ can be conceived of as ‘hybrid’ (Bridges and Pascoe, 2014), ‘inclusive’ (Anderson, 2005) or ‘pastiche’ (Atkinson, 2010). In general, it is argued that boys and men are embracing skills, practices and values once aligned to women and femininity. For example, Anderson’s work points to a softening of (heterosexual) masculinity whereby young men are comfortable in expressing affection for male peers and enjoy the company of women and gay friends. However, we do not know how far inclusive masculinity is enacted outside particular milieus (most of Anderson’s research participants have been university ‘jocks’), and some argue that by taking on practices conventionally associated with marginalized others (women, gay men, ethnic minorities), hegemonic masculinity is simply being repackaged by elite men to maintain their power and privilege in a changing world (see Bridges and Pascoe, 2014). What contemporary masculinity theory means for men’s health is clear: we should not assume that all men are poor at looking after themselves. Rather, we should acknowledge that some men may in fact prioritize their health and adopt ‘salutogenic masculinities’, that is, gendered practices and identities which improve health and well-­being (see Sloan et al., 2009; Gough and Robertson, 2009). We must move away from generalizing about all men to studying how individual and subgroups of men orient to health-­related issues so that more informed and tailored interventions can  be  devised.  This point applies equally to mental health promotion, as we argue below.

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Men, ‘masculinity’ and mental health  ­137

MALE MENTAL HEALTH AND MASCULINITIES Mental health conditions are among the most common health problems. In England, it is estimated that one in four people are affected by a mental health problem in any one year and the aggregate cost of mental health conditions was £105.2 billion in 2009/10 (Centre for Mental Health, 2010). As with physical health statistics, there are some striking sex difference statistics to be found. Overall, it is suggested that men and women are almost equally at risk for the most severe mental disorders, such as psychotic illnesses (Payne, 2006: 93) with previous year prevalence being 0.3 per cent in males and 0.5 per cent for females (Sadler and Bebbington, 2009). However, there are some interesting and notable differences. In schizophrenia, men are thought to have higher rates (though this is contested), tend to develop it earlier in life than women (around age 15–20) and often suffer more negative symptoms (lack of interest, emotional flatness, inability to concentrate) than women (Ochoa et al., 2012). Women attempt suicide far more frequently than men, yet rates for male suicide are approximately three times higher than those for female suicide (Oliffe et al., 2011), and depression is one of the most common factors implicated in suicide cases ­(Möller-­Leimkühler, 2003). It is well established that fewer men than women are treated for depression-­related disorders within England (Richards and Borglin, 2011), reflecting a similar situation across the Global North (Addis, 2008; Addis and Cohane, 2005). Common mental health problems relating to depression and anxiety (generalized anxiety disorder, panic disorders, phobias and obsessive compulsive disorder) are those conditions that cause distress and interfere with daily function, but do not generally impact on cognition or insight. Overall rates of anxiety and depression are lower in males, with 13 per cent of males and 20 per cent of females reporting an episode in the last week (Deverill and King, 2009). However, men of different ages, nationalities, racial and ethnic backgrounds are less likely to seek help than women (Addis and Mahalik, 2003). Distress in men may be exhibited more indirectly, for example through alcohol and substance misuse and addiction (DH, 2012), anger and aggression towards self and others (Wilkins, 2010), and risk-­taking more generally (Courtenay, 2000). As with physical health, particular groups of men are more vulnerable to mental health problems. Black and minority ethnic (BME) males have a prevalence of 3.1 per cent compared to 0.2 per cent amongst white males (Sadler and Bebbington, 2009) and elevated rates of psychosis amongst ethnic minority males have also been reported elsewhere (Centre for Social Justice, 2011). Prevalence of such disorders is also more common amongst divorced males at 1.5 per cent, which is 15 times higher than amongst married men, five times higher than amongst single men and 2.5 times higher than amongst cohabiting men (Sadler and Bebbington, 2009). Suicidal thoughts and suicide attempts were three times higher amongst divorced men, and two times higher amongst separated men, when compared to married men. Both suicidal ideation and suicide attempts amongst men (and women) show a clear gradient in relation to household income, with the lower prevalence amongst those with highest income and greatest prevalence in the lowest-­ income households (Ministry of Justice, 2009). In times of economic austerity, unemployment, low-­paid unstable work and financial hardship can undermine conventional masculine investments (breadwinner, protector) and lead to psychological difficulties (Samaritans, 2012). Male prisoners, who are predominantly young and disadvantaged,

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138  Handbook on gender and health are a particularly vulnerable group: the proportion of male prisoners with psychosis is 14 times higher than in the general population (7 per cent versus 0.5 per cent), while higher rates of suicide amongst prisoners have been found in many countries (Mental Health Network, 2011; Fazel and Baillargeon, 2011). Men also constitute the majority of single homeless people in England, another group vulnerable to mental illness (Crisis, 2011). It is also important to point out that rates of mental illness are likely to be significant for men in the Global South, but research here has tended to focus on major public health challenges like HIV in many African countries (see Skovdal et al., 2011). It is important then to consider how masculinities intersect with other systems of difference and inequality related to, for example, social class, race, ethnicity, age, sexuality, regional context and disability – an intersectional approach (Griffith, 2012). It is well known that the mental health of poor, disadvantaged and marginalized groups is worse than that for more affluent, elite groups (Fernando and Keating, 2009). Psychological difficulties experienced by BME men are linked to exposure to racial violence, stigmatization and prejudice (Robinson et al., 2011); young men from tough neighbourhoods may be socialized into gangs, violence against others, sexual objectification of women (online and offline), emotional suppression and substance abuse (Sanders, 2012); rates of depression, anxiety and attempted suicide are found to be higher in gay men compared to men in general (Guasp, 2012). Clearly, for such marginalized and subordinated groups of men, restricted access to benefits, opportunities and resources enjoyed by more privileged groups means that they may be limited to a narrow range of (toxic) masculine identities and less likely to engage with mainstream psychological services (Wilkins, 2010). But since some men do disclose distress and seek help, it is important to analyse why and how such men have taken steps to recognize and manage their problems. A growing body of qualitative research in this area is beginning to shed light on men’s constructions of ­distress, support – and masculinities.

MASCULINITIES ‘Masculinity’ has been proposed as the reason why so many men within the Global North are reluctant to report mental health problems or seek professional help (Addis and Mahalik, 2003). Quantitative research has highlighted sex differences in coping with depression, for example indicating that women adopt more (positive) coping strategies compared to men (for example, Tamres et al., 2002). A review of 200 studies (largely based in the USA) using the Gender Role Conflict Scale found that masculine gender roles were associated with psychological distress and dysfunctional relationships for men in many different countries (Blazina and Shen-­Miller, 2011; O’Neill, 2008). Work focusing specifically on men’s coping styles implicates the role of masculinity norms, including self-­reliance, emotional repression and risk-­taking (Mahalik et al., 2007). The literature suggests that help-­seeking is coded as weakness, which leads to an avoidance of psychological services, or long delays between problem recognition and help-­seeking, which is usually prompted by a crisis (for example, bereavement, divorce, chronic illness). This typical delay has been read in terms of masculinity: an attempt to be stoical, self-­contained and strong (for example, Davidson and Meadows, 2010; Johnson et al., 2012). It has also been noted that men may delay help-­seeking out of concerns

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Men, ‘masculinity’ and mental health  ­139 about being patronized, judged or criticized by health care professionals (Seymour-­Smith et al., 2002), and there is some evidence that doctors and nurses reproduce traditional notions of masculinity, for example in valuing stoical male patients who consult infrequently and only for serious problems, while regarding frequent attenders as less ‘manly’ (Hale et al., 2010). Similarly, help-­seeking letters submitted to ‘experts’ within male-­ targeted magazines found that responses often positioned the men in question in terms of compromised, failed or insufficient masculinity (Anstiss and Lyons, 2014). This reluctance to seek support has also been linked to a preference for self-­ reliance and autonomy among men; features traditionally linked to masculinity norms (Courtenay, 2000). Men who experience distress are also more likely than women to self-­medicate through excessive alcohol consumption or substance misuse, a form of ‘maladaptive coping’ or ‘masked depression’ (Addis, 2008; Oliffe et al., 2012). This observation has led some scholars to call for dedicated assessment scales which can pick up depression in men who present with different symptoms than women; indeed, some have developed specific measures, such as the Gotland Scale (Martin et al., 2013), for more accurately picking up depression in men. These scales focus on recognition of what authors call ‘alternative symptoms’ (such as aggression, anger, substance misuse), as well as incorporating ‘traditional symptoms’. When used, these scales show that rates of depression are much more equal between men and women than when using traditional measures, suggesting that much male depression currently remains hidden from clinical view (Martin et al., 2013). Brownhill et al. (2005) have identified a framework showing how this process of gender socialization in Western countries leads men to cope with mental health concerns (particularly depression) in ways that escalate; what they call the ‘big build’. They suggest that men initially begin with behaviours they term ‘acting in’, which include strategies of ‘avoidance’ (such as overwork), ‘numbing it’ (through drug or alcohol use) and ‘escaping it’ (through increased risk-­taking behaviours like excessive drugs and alcohol, gambling or extra-­marital affairs). If such mechanisms are not able to ameliorate the feelings of depression they can lead to ‘acting out’ behaviours, which include more of the ‘escaping it’ behaviours outlined above, which can escalate further to ‘hating me, hurting you’ (acts of violence, aggression and crime) and ‘stepping over the line’ (deliberate self-­harm and suicide). When a crisis then hits home, standard ‘masculine’ rules may be justifiably suspended in extremis so that support may be reviewed as positive and necessary rather than a sign of softness (O’Brien et al., 2005). For example, one study reports that urban African-­ American men were minded to visit their physician in response to the deaths from cancer of their fathers, who left it late to seek medical help (Griffith et al., 2011). Outside of personal crises, some men will be enabled by their circumstances (supportive partner, work environment, peers and so on) to feel more comfortable in accessing and engaging psychological services, especially if they have earned enough masculine ‘capital’ to deter any censure from male peers (de Visser et al., 2009). For example, one study notes that the expression of distress and help-­seeking within the military is supported by military peers only if the individual in question had previously established himself as an effective soldier (Green et al., 2010). There is also evidence that female partners can play a role in encouraging men to seek help, providing a ready-­made face-­saving rationale (‘my wife ordered me to come’: Seymour-­Smith et al., 2002; see also Hale et al., 2010). This

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140  Handbook on gender and health evidence reminds us that those men without partners (for example, divorced, widowed) may be especially vulnerable and disinclined to seek help (Davidson and Meadows, 2010). Other qualitative studies have found that help-­seeking may be reframed in masculine ways: men may position themselves or be positioned by others as brave, strong or even heroic for coming forward. For example, a study by Noone and Stephens (2008) found that older men construed themselves as ‘legitimate users’ of health services, in contrast to women who were positioned as frequent and trivial attenders, and to other men who did not use services, positioned as naive or ignorant. In this way, help-­seeking is equated with control, rationality and agency rather than weakness, or even as the pursuit of action and achievement (Johnson et al., 2012). Alternatively, help-­seeking may be framed as a means of protecting or advancing valued masculinized roles and capacities, including occupational, familial and educational responsibilities. For example, Kim et al. (2001) found that some Asian men were more likely to seek help if academic achievement – a greatly cherished objective – was under threat. Another study reported that older men justified seeking help when it related to sexual functioning, an important identity-­relevant practice (Calasanti et al., 2013). In terms of managing distress, men may also turn profitably to elements of hegemonic masculinity. Emslie et al. (2006) found that, among a group of middle-­aged men experiencing depression, ideals of control, responsibility to or for others, and being ‘one of the boys’ helped to (re-­)establish a sense of identity as the men attempted to survive and recover from depression. However, some of the men also emphasized the importance of creativity, sensitivity and intelligence in identity formation, specifically positioning these attributes (and therefore themselves) as being in opposition to some traditional, stereotypical aspects of masculinity and as a positive part of a redefined self as they attempted to deal with depression and its consequences. This resonates with work by Valkonen and Hänninen (2012), whose interviews with men with depression in Finland suggested that such depression could be a consequence of both achieved and unattained hegemonic masculinity, but also that men could both challenge and utilize hegemonic norms as a resource for coping with mental distress. They concluded that there is not a single type of association between masculinity and depression. Expanding on this work, Oliffe et al. (2011) interviewed 26 couples where the men self-­ identified as having depression. They identified three patterns of coping: ‘trading places’, where the couples exchanged certain stereotypical roles (such as the breadwinner role); ‘business as usual’, where couples strived to maintain stereotypical roles and thereby conceal any possible ‘depression-­induced deficits’; and ‘edgy tensions’, where there was disharmony and/or disagreement in relation to expected roles, leading to resentment and threats to sustaining the relationship. To this extent, men’s depression is obviously more than an individual experience; rather, it is influenced by a range of intersubjective encounters. Other recent work has indicated that some men appreciate the emotional support offered by partners, family and peers (Ramirez and Badger, 2014), including fellow depression sufferers, who can help to normalize the situation (Cutcliffe et al., 2013). In a related study, Oliffe et al. (2012) interviewed 38 men to explore depression-­ related suicidal ideation. Recognizing the importance of ‘masculine protector’ and fathering roles helped the men to position help-­seeking as the rational action and assisted with regaining a sense of self-­control. In line with Brownhill et al.’s (2005) work mentioned earlier, an alternative pathway for the men was ‘escaping’, for example through

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Men, ‘masculinity’ and mental health  ­141 excessive alcohol or drugs. This pathway was far more negative, often increasing feelings of isolation and heightening vulnerability to suicidal actions. Work by Galasiński (2008) focusing on discourses identified in interviews with men with depression highlighted that the men interviewed did not really engage with medical models of depression that focus on ‘low mood’; instead, they were more concerned with the social experience and impact. Like other research, he highlights the men’s orientation to masculinities in constructing and managing depression: the men in his study provided stories (narratives) of depression that were underpinned by the social expectations of what it is to be a man. Again these were presented as both ‘success’ stories, where elements of hegemonic masculinity were utilized within these narratives to present a positive male identity despite depression (or even in order to help defeat or control the depression), and ‘failure’ stories, where the men’s suffering because they could not achieve hegemonic norms loomed large in their experience. In dealing with depression, then, traditional masculinity ideals may be deployed and/or non-­traditional elements reimagined as masculine.

‘MALE-­FRIENDLY’ INTERVENTIONS As discussed above, we know that relatively few men voluntarily choose to report distress and access psychological services, and that investment in hegemonic masculinities is significant here. Considering service provision, however, it is striking that the majority of counsellors, therapists and clinical psychologists are female (and that senior service commissioners, leaders and policy-­makers are mostly male) (see Morrison et al., 2014). This feminized domain, like other areas of health care (for example, maternity, family planning, sexual health), may possibly deter some men from coming forward. Another factor which may constrain men from using services is restricted opening hours – more men than women work full-­time and therefore have less flexibility to access care (Equality and Human Rights Commission, 2013) – although policy is shifting so that more GP surgeries and specialist services are now offering extended opening hours. When men do access services their symptoms may be misread and mistreated since their distress presentation may well veer from standard checklists (for example, violence, alcohol abuse, psychosomatic gastric problems and so on; Wilkins, 2010). Morrison and Laing (2011) analysed population data from Alberta which showed that 90 per cent of men who committed suicide had accessed professional health care services at least once in the year before taking their own lives. If referred to psychological services, the traditional focus on emotion talk may discourage some men, leading to disengagement. Men may prefer to focus on thoughts rather than dwelling on feelings, so cognitive (for example, Cognitive Behavioural Therapy, CBT) and mindfulness (Lomas, 2014) interventions may be attractive. Another advantage of CBT for men is its pragmatic, problem-­solving focus; an instrumental coping style that men supposedly favour (Lazarus and Folkman, 1984; Robertson, 2007). The provision of specific homework tasks also enables men to take some control over their mental health and the mere expression of agency here may facilitate progress. Since men as a whole do not use psychological services, some mental health organizations have tried to leverage ‘masculinity’ in order to encourage men to come forward. In this context, help-­seeking can be reframed in terms of toughness and independence, while marketing discourse and imagery may invoke sport, war or work

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142  Handbook on gender and health references (see Samaritans, 2012). One example of a male-­ specific psychotherapeutic approach has been developed in the USA by Levant and colleagues: ‘Alexithymia Reduction Treatment’ (ART; Levant et al., 2009). Alexithymia is defined as an inability to identify and articulate feelings, which many regard as a core element of traditional masculinity; certainly men have been found to be more ‘alexithymic’ than women (Levant et al., 2006). The focus of ART is on developing emotional skills through a series of exercises focusing on emotional language, perception and self-­monitoring, and although there is some evidence of change in masculinity, the impact on help-­seeking and coping with distress is not known. In recent years various attempts have been made to develop ‘male-­friendly’ mental health interventions. Because of the stigma around psychological issues and the ­‘masculine’ avoidance of emoting, many of these initiatives are situated in community settings and may not advertise their services in mental health terms. A lot of these community-­based programmes target specific groups of men who may have proved especially hard to reach, including young men, BME men, unemployed men, retired men, military veterans and disabled men. Often, the focus of these interventions is on activities, which may range from sport and physical activity to do-­it-­yourself (DIY)-­type jobs, information technology (IT) and educational sessions. A good example is the Men’s Sheds initiative which has targeted older, isolated men to join a group who make things together which may then be used in their communities. The UK Men’s Sheds Association (www.menssheds.org.uk) states that there are now over 80 Sheds in the UK. Such initiatives characterize a ‘shoulder-­to-­shoulder’ rather than ‘face-­to-­face’ approach where men do emotion indirectly, side by side, in the context of another activity (see Robertson, 2006). Many of these programmes build in social space and time where men can enjoy each other’s company, learn to trust others and gradually work through any problems they may be experiencing. Workplace settings also present opportunities for male mental health promotion since many men work full-­time and regard work as important for their identities (see Oliffe and Han, 2013 for a review of men’s mental health at work). The adoption of local non-­medical discourse can be seen in some interventions: the suicide prevention charity Campaign Against Living Miserably (CALM) (www.thecalmzone.net) refers to ‘feeling shit’ rather than ‘being depressed’, and uses musicians and actors as ambassadors to communicate with men and does not script what they say or expect them to use medical language. With such programmes there is a balance to be struck between invoking strengths-­based masculine ideals and challenging some of the more restrictive aspects of masculinity. Sporting environments have also proved successful. For example, It’s a Goal (www.itsagoal.org.uk) is an 11-­week therapeutic programme based at football venues which uses football metaphors to reach men with mental health needs. Similarly, Time to Change (www.time-­to-­change.org.uk/), the UK anti-­stigma mental health campaign, has used football metaphors in resources aimed at encouraging men to talk about mental health problems. Leaflets and ‘top tips’ cards are branded: ‘Is your mate off his game? . . . Get on the ball about mental health’. In addition, this and other programmes deploy humour in sessions and resources in order to encourage men to talk to their friends about mental health problems. These community programmes vary in terms of professional and peer input. In some cases, professional psychological input may be available or advertised within the

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Men, ‘masculinity’ and mental health  ­143 c­ ommunity space, while in others the focus is very much on peer support. Peers may be trained by professionals and are well placed to refer men on to other services, and if peer facilitators hail from the same community then they are more likely to be respected and responded to. In general the more a service can be designed, developed and delivered with community members from the start, where local values, language and facilities are central, the more chances of community buy-­in and success (see Robertson et al., 2013). Another alternative form of mental health service provision, particularly for younger men, relates to phone and online programmes. CALM (www.thecalmzone.net) receives many calls to its telephone helpline, mostly from men. CALM also provides a webchat service, with text and online options especially popular with younger men, who may start with text, then move to talking on the phone. Relate (www.relate.org.uk) also provides telephone counselling, email counselling and live online chat. Online provision can range from discussion forums and support groups involving peers to email and messaging forms of counselling. Because so few men access traditional talking therapies, the anonymity afforded by the Internet may encourage some men to disclose personal problems in ways they would not ordinarily do. Websites and online resources are hosted by a range of non-­governmental organizations (NGOs) and may be general (for example, menshealthforum.org; CALM) or address a particular problem or constituency (for example, mengeteatingdisorderstoo.co.uk). One initiative in Australia used a computer game format to tackle mental health issues in young men, with the game incorporating CBT elements as well as developing skills in problem-­solving and communication (Burns et al., 2010). However, despite initial popularity, we do not yet know how effective such interventions are in the medium to long term. To date there is little research which examines or evaluates online mental health provision for boys and men. A recent study (Gough, 2015) indicates that, despite the popular view that informal peer support is easy to access in online forums, only men who gave a convincing account of their depression were deemed credible and worthy of support. For example, a medical diagnosis was preferred and if not available men had to provide lots of detail about depression-­related problems, convince others they were not to blame, demonstrate that they had tried hard to overcome their depression (for example, though diet, abstention from alcohol, and exercise) before recognizing medication as a last resort. In Canada, the Men’s Depression ‘Help Yourself’ website (http://www.mensdepressionhelpyourself.ubc.ca/) showcases the findings drawn from a programme of research on masculinities and men’s depression. Focused on college, middle-­aged and older men, content is targeted to specific age groups amid offering guidance about men’s depression through video vignettes drawn from men experiencing depression and health care providers who treat men’s depression. There is consensus that men’s e-­mental health content should be evidence-­based and interactive as a means to fully engage men. Web interactivity has tended to include videos and quizzes. Testimonials have been featured in videos and this approach can help to explain and normalize specific symptoms and mental illnesses based on men’s lived experiences as well as to provide insights about service providers and treatment options. In terms of quizzes, some guide men towards the services that they might need based on end-­user responses to specific items. Some e-­mental health approaches provide men with opportunities to compare themselves to others, self-­assess and research specific concerns anonymously. The content is either audience-­specific (for example, by age group on the Help Yourself website) or tailored based on the men’s responses. The

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144  Handbook on gender and health e-­mental health resources also allow men time to consider their responses, and 24/7 access to content, both of which emerge in contrast to traditional time-­limited face-­to-­ face consultations. In sum, a range of promising interventions are emerging in the field of men’s mental health which largely take place in community settings, are tailored to a particular group (for example, young men, BME men, gay men), focus on ‘doing’ rather than (or as well as) talking, use language and materials which have local currency, offer peer as well as professional support, and encourage men to self-­manage where appropriate. Generally, these interventions draw on valued masculinities to encourage access and engagement and to demonstrate that in the right contexts men will come forward and work with others to tackle psychological problems (however indirectly) and improve their well-­being. Despite positive indications, there is still work to be done in researching men’s mental health within different local, regional and international contexts (especially the Global South); evaluating recent programmes which show promise, including online  ­services; and in developing and delivering improved mental health service ­provision for men.

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Schizophrenia Research and Treatment, Vol. 2012, Article ID 916198. doi:10.1155/2012/916198. Oliffe, J. and Han, C. (2013) Beyond worker’s compensation: men’s mental health in and out of work, American Journal of Men’s Health, 8(1): 45–53. Oliffe, J., Kelly, M.T., Bottorff, J.L., Johnson, J.L. and Wong, S.T. (2011) ‘He’s more typically female because he’s not afraid to cry’: connecting heterosexual gender relations and men’s depression. Social Science and Medicine, 73(5): 775–782. Oliffe, J., Ogrodniczuk, J.S., Bottorff, J.L., Johnson, J.L. and Hoyak, K. (2012) ‘You feel like you can’t live anymore’: suicide from the perspectives of Canadian men who experience depression. Social Science and Medicine, 74(4): 506–514. Payne, S. (2006) The Health of Men and Women. Cambridge: Polity Press. Ramirez, J.L. and Badger, T.A. (2014) Men navigating inward and outward through depression. Archives of Psychiatric Nursing, 28: 21–28. Richards, D.A. and Borglin, G. (2011) Implementation of psychological therapies for anxiety and depression in routine practice: two year prospective cohort study. Journal of Affective Disorders, 133: 51–60. Robertson, S. (2006) ‘I’ve been like a coiled spring this last week’: embodied masculinity and health. Sociology of Health and Illness, 28(4): 433–456. Robertson, S. (2007) Understanding Men and Health: Masculinities, Identity and Well-­being. Buckingham: Open University Press. Robertson, S. and Williams, R. (2009) Men: showing willing. Challenging common assumptions and considering men’s own accounts will help health practitioners to understand men’s use of health services. Community Practitioner, 82(4): 34–35. Robertson, S. and Williams, R. (2012) The importance of retaining a focus on masculinities in future studies on men and health. In: Tremblay, G. and Bernard, F. (eds), Future Perspectives for Intervention, Policy and Research on Men and Masculinities: An International Forum. Harriman, TN: Men’s Studies Press. Robertson, S., Witty, K., Zwolinsky, S. and Day, R. (2013) Men’s health promotion interventions: what have we learned from previous programmes?. Community Practitioner, 86(11): 38–41. Robinson, M., Keating, F. and Robertson, S. (2011) Ethnicity, gender and mental health. Diversity in Health Care, 8: 81–92. Sadler, K. and Bebbington, P. (2009) Psychosis. In: McManus, S., Meltzer, H., Brugha, T., Bebbington, P. and Jenkins, R. (eds), Adult Psychiatric Morbidity in England, 2007: Results of a Household Survey. Leeds: NHS Information Centre for Health and Social Care. Samaritans (2012) Men, suicide and society. Research report. www.samaritans.org. Sanders, B. (2012) Gang youth, substance use, and drug normalization. Journal of Youth Studies, 15(8): 978–994. Seymour-­Smith, S., Wetherell, M. and Phoenix, A. (2002) ‘My wife ordered me to come!’: a discursive analysis of doctors’ and nurses’ accounts of men’s use of general practitioners. Journal of Health Psychology, 7(3): 253–267. Skovdal, M., Campbell, C., Madanhire, C., Mupambireyi, Z., Nyamukapa, C. and Gregson, S. (2011) Masculinity as a barrier to men’s use of HIV services in Zimbabwe. Global Health, 7: 13.

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Men, ‘masculinity’ and mental health  ­147 Sloan, C., Gough, B. and Conner, M.T. (2009) Healthy masculinities? How ostensibly healthy men talk about lifestyle, health and gender, Psychology and Health, 24(1): 1–21. Tamres, L., Janicki, D. and Helgeson, V.S. (2002) Sex differences in coping behavior: a meta-­analytic review. Personality and Social Psychology Review, 6: 2–30. Valkonen, J. and Hänninen, V. (2012) Narratives of masculinity and depression. Men and Masculinities, 16(2): 160–180. Wilkins, D. (2010) Untold Problems: A Review of the Essential Issues in the Mental Health of Men and Boys. London: Men’s Health Forum.

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9.  Stigmatized, marginalized and overlooked: health, later life and gender in India and the United Kingdom Penny Vera-­Sanso

INTRODUCTION Dominant discourses and conceptual frameworks tend towards stereotypical understandings of what ‘the issues’ are for older people. This forces research, policy framing and everyday discourse down predictable pathways. In neoliberal Britain, where a discourse of ‘austerity’ is being used to reduce social protection, that pathway mainly consists in defining older people as an unaffordable social burden and in constituting later life as an object for intense statistical analysis. In neoliberal India, where social provision for older people is negligible, the dominant discourse classes older people as the responsibility of families and of limited research interest, especially by comparison to women and children. In both contexts, stereotypical discourses on frailty, disability, dependence, isolation and family neglect marginalize other perspectives, with the result that research into old age rights (or their lack) and into later life activity, participation, independence, contribution, productivity and mutual interdependence across generations tend to be framed as policy objectives (‘active ageing’) rather than empirical realities. These stereotypical discourses on old age locate health in the body, in access to health practitioners and in being cared for. This chapter will challenge these stereotypes by demonstrating how a focus on what older people do, that is not predetermined by  ageist thinking, produces a broader understanding of what determines health in later life.

HEALTH AND WELL-­BEING IN LATER LIFE Research on older people tends to take descriptive population measures, especially average life expectancy at birth, as proxies for health and well-­being (Higgs et al., 2003) and it is commonly, though erroneously, thought that it is only in the twentieth century and in developed countries that life spans have extended beyond middle age (Thane, 2005; Bloom et al., 2015). The main population descriptor, life expectancy at birth, provides an average heavily distorted by deaths in the first five years of life, and cannot be taken as a proxy for longevity or later life health. For example, in India in 1960 the average life expectancy at birth was 42 years, which rose to 66 years in 2013 (World Bank). This would suggest that living into late old age would not be widespread in India and certainly would be less likely to occur amongst those at the lower end of the social hierarchy. However, photographs from the late nineteenth century and watercolours from the early nineteenth century demonstrate otherwise: they depict many aged people 148 Jasmine Gideon - 9781784710859 Downloaded from Elgar Online at 11/03/2017 02:47:53AM via Sydney University

Health, later life and gender  ­149 at work, as agricultural labourers, as potters, scribes, stone workers, servants, weavers, spinners, and so on. The underused average life expectancy at age 60 provides a better comparative measure of average longevity. In the United Kingdom (UK) the average life expectancy at birth was 81 years in 2013 but at age 60 it was 25 years for women and 22 years for men, meaning that if women reached the age of 60 then, on average, they will live to age 85 (GHO, 2015). Healthy average life expectancy (HALE) at age 60 provides the number of years a person can expect to live in full health, defined as not suffering from disease and injury, from the calculation point – in this case age 60. In 2002, the UK HALEs at age 60 were 18 years for women and 15 years for men (WHO, 2004). In India, in 2013, while average life expectancy at birth is 68 years for women and 65 years for men, at age 60 it was 18 years for women and 16 years for men (GHO, 2015), and HALEs at age 60 were approximately 11 years for both men and women in 2002 (WHO, 2004). This means that women that reach the age of 60 will on average live to 78, but as it is an average, may live much longer, and approximately 11 of those years are likely to be in good health. For men reaching 60 they would on average live till aged 76, but once again, about 11 of those years are likely to be in good health. In both countries the main killers are no longer the communicable diseases that kill children but the non-­communicable diseases of middle and later life. India also has high rates of death from suicide, road traffic accidents, diarrhea and tuberculosis, demonstrating the need to broaden the analysis of what constitutes a health issue well beyond the body and take a broader focus on well-­being. However, in relation to older people health is treated as a proxy for well-­being, which reinforces the negative view of ageing as decline and older people as dependent, ignoring their capacity to adapt and compensate for changes in health and mobility (Higgs et al., 2003). The World Health Organization recognizes this need to broaden the concept of health and health outcomes by promoting an active ageing agenda to ‘realize (older people’s) potential for physical, social and mental well-­being . . . to participate in society according to their needs, desires and capacities, while providing them with adequate protection, security and care when they require assistance’ (WHO, 2002: 12). The main determinants of active ageing identified by the WHO are culture and gender, health and social services, behavioural determinants, the physical and social environments, economic determinants and individual determinants (genetics and psychology) (WHO, 2002), and these require linkage to health, social and economic policy (Walker, 2014) and to infrastructural provision in developing countries. In 2002 the United Nations adopted the Madrid International Plan of Action on Ageing (MIPAA) which defined the policy agenda to secure active ageing. Priority 1 is that older people must be ‘full participants in the process of development and also share in its benefits’ (UN, 2002: cl. 16). Priority 2 is that older people are ‘fully entitled to have access to preventative and curative care’ (cl. 58) and Priority 3 is ‘ensuring an enabling and supportive environment’ in order to ‘empower older persons and support their contribution to society’ (cl 94). India and the United Kingdom are both signatories to MIPAA. Older’s people’s right to participate in and benefit from development was overlooked by the Millennium Development Goals (MDGs) and marginalized by their focus on maternal health, on children’s health and education, and on women’s empowerment; in practice older women fall out of the frame in conceptualizations of ‘women’ as a category unmarked by age. The Sustainable Development Goals, which include developed and

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150  Handbook on gender and health developing countries, where the MDGs did not, are also likely to be detrimental to older people. The current version of Goal 3 is to ‘ensure healthy lives and promote well-­being for all at all ages’; and Target 3.4, which will be the key measure of attainment of the goal, reads: ‘By 2030 reduce by one third premature mortality from non-­communicable diseases.’ Death before the age of 70 is described as ‘premature’, yet in the UK the average life expectancy at age 60 for women would suggest that they can expect to live to 85, and for women in India until they are 78, and many will live much longer. It is highly unlikely that India and the UK will be adding sufficient new resources to meet this goal and they are much more likely to refocus resources on people aged below 70. Not only would this formulation of ‘premature’, rather than ‘preventable’, deaths increase the likelihood of those most at risk from non-­communicable diseases (NCDs) being denied health services, but it sends the message that at age 70 death is to be expected and preventative, curative and care services are not warranted by comparison to others’ needs. Clearly this negates MIPAA and the fundamental human rights that older people have as people, and reinforces the stereotypical discourse of frailty, decline and dependence. For a global institution, with its aura of rationality, objectivity, and authority, to underscore an ageist discourse with an implicit ‘expiry date’ exposes all older people to further stigmatization and discrimination and especially older women who live longer, whose unremunerated work for family and society is disregarded and who have accumulated less resources over a life course marked by gender discrimination in relation to education, incomes, pensions and assets.1

CONFRONTING STEREOTYPICAL DISCOURSE IN THE UNITED KINGDOM In the UK health and health-­related research on older people typically focuses on mental health, in terms of loneliness and isolation, on care needs, in terms of disability and dementia, on non-­contagious diseases, on food and fuel poverty and disability-­ appropriate housing. This narrow scope reflects and drives policy, deepening ageist stereotyping (Vincent, 2006) and generating social divisions by constructing older people as ‘other’ (Katz, 1996) and as a burden on younger generations (Quadagno, 1989; Vincent, 1999; Walker, 1990). Yet, barring dementia, none of these health needs can be remotely described as primarily ‘old age issues’, but can affect people at any stage in the life course. Even to describe dementia as characteristic of old age is a significant distortion. In the United Kingdom the research, political and media discourses on dementia are increasingly alarmist. In December 2013 David Cameron, Prime Minister of the United Kingdom, called dementia a ‘21st century plague’ and a ‘global challenge’ at the first G-­8 Dementia Summit held in London (Dobson and Dobson, 2014). Disturbing absolute figures of dementia cases and highly questionable costs to the economy are regularly trotted out by a wide range of experts and opinion-­shapers, demonstrating the dangers of trying to raise the profile of a cause in a neoliberal context where costs to the economy will draw attention but can also stigmatize and further deepen the stereotyping of particular social groups. While Cameron backed his calls to life science companies’ investment in UK research and to G-­8 countries to share knowledge by claiming that dementia

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Health, later life and gender  ­151 will affect one in three persons and that it costs the world $600 billion per year, more reliable sources also feed into this stigmatizing discourse. The Alzheimer’s Society commissioned researchers at the London School of Economics  and Kings College, London, to undertake a meta-­analysis of the cost and prevalence of dementia in the UK (Prince et al., 2014). If we invert the presentation of their results, by presenting proportions of people without dementia rather than focusing on those who have dementia, we can see that dementia is more associated with old age than earlier life stages, but by no means is it characteristic of old age. In absolute terms the number of people with dementia, irrespective of age, might appear large, estimated at 850 000 in the UK; in fact this represents a tiny percentage (1.3 per cent) of the entire UK population. Bearing in mind that according to the 2011 Census 16 per cent of the UK population is aged 65+ (Office for National Statistics, 2011), it becomes clear that while 95 per cent of people who have dementia are aged 65+, 93 per cent of people aged 65+ do not have dementia.2 Similarly, Prince et al. (2014) report that 29 per cent of people aged 90–94 have dementia, meaning that more than 70 per cent do not, and their figures indicate that nearly 60 per cent of people aged over 95 do not either. The report devotes 26 pages, a quarter of its text, to estimating the cost of dementia to the UK. After exploring how to estimate health care, housing, social care, unpaid care, police costs, fire service costs, research costs, advocacy costs and £20 000 per lost year of life (from premature mortality of, on average, 18 months for men to two years for women), much of which was unsuccessful, it produced an annual estimate of £26.3 billion. To achieve this figure for such a tiny percentage of the population (1.3 per cent), the report builds in £11.6 billion in unpaid care costs, setting values for this unpaid care that ranged from commercial replacement costs (£19 per hour), the national average wage (£15.50 per hour) and the National Minimum Wage for the carers’ age bands. Carers aged 65+, being presumed to be retired, were allocated £6 per hour, demonstrating that even in the imagined world of hypothetical research older people are not thought to deserve equal pay for equal work.3 When we consider the lack of policy recognition to other unpaid care, including the care of children and workers (to make them fit and presentable for the next day’s work) and the UK’s Carer’s Allowance for carers of people with ‘substantial caring needs’ (£62 per week), it is difficult to see the justification for putting forward a figure of £11.6 billion on unpaid care for people with dementia. The inconsistency in approach demonstrates that estimated costs need to be examined not in terms of their methodological shortcomings as a piece of research, but as an intervention in the public perception of older people. By defining the unpaid element of dementia care as an unaffordable cost to the UK, when it is not defined as such in relation to ill-­health, children, workers and (slightly less aggressively) disabled people, there is no alternative to the judgement that ‘data’ are being constructed. While it is unlikely that the Alzheimer’s Society intended such, the alarmist presentation of the prevalence and costs of dementia can only fuel ageist stereotypes, stigmatizing all older people as a potential social burden, and in an ‘austerity’ policy context fuelling the view that older people are soaking up social resources (pensions, national health services) at younger people’s expense. The credibility and effectiveness of such research, as an intervention in the public perception of older people, lies in its confirmation of ageist stereotypes: the view that older people are frail, dependent and disengaged from society and that it is younger

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152  Handbook on gender and health generations who are socially and economically active and on whom society and economy depend. Yet nearly a quarter of people aged 16–64 in England and Wales are not ‘economically active’, meaning they are neither working nor seeking work (Office for National Statistics, 2015a). Whereas nearly 1 million people in England and Wales aged 65+ are in work, comprising about 10 per cent of people aged 65 and over, and representing 3.5 per cent of the workforce (Office for National Statistics, 2015b). Sara Arber’s analysis of the University of Essex’s Understanding Society Survey interview data of more than 11 000 men and women aged 60–79 finds that 21 per cent of women and 18 per cent of men aged 65–69 are working (Arber, 2015). In the UK as a whole, 20 per cent of unpaid carers are over 65, amounting to 1.3 million carers, and this is the fastest-­growing group of carers, growing three times faster than any other age group (Carers UK, 2014). The fastest-­growing group is aged 85 and over, 60 per cent of whom are men, and more than half of carers aged 85 or more provide 50 or more hours of care per week (Carers UK and Age UK, 2015). By age 59 half of women, and by age 75 half of men, are carers (Carers UK, 2014), caring for spouses, children, grandchildren and friends. In terms of child care alone, informal care plays a larger role in most families than does market-­based care, and grandparents, particularly the mother’s parents, are the most important providers of informal child care (Wheelock et al., 2003); the importance of grandparents’ care work extends to filling the ‘parenting gap’ between working parents and adolescents (Tan et al., 2010). The most frequent formal volunteers in the UK are aged 65–74 and nearly 30 per cent of people aged 75+ are involved in formal volunteering through a group, club or organization (NCVO, 2015). These figures do not include informal volunteering to help cover social needs not, or inadequately, met by the state, including child care, volunteering in schools, hospitals, hospices and out-­of-­school activities. A number of studies recently undertaken in the UK have placed older people’s experiences at the centre of research, and this approach has demonstrated that older people are socially connected and contribute significantly to their communities and families but that their participation is hampered, unacknowledged or undervalued (Vera-­Sanso et al., 2014). Cumulatively the conclusion from these studies is that widespread negative stereotypes and prejudicial discourses about older people’s needs, wants and capacities drive the overlooking of their social and economic contributions and marginalization of their rights and leave these factors out of the equation in investigating older people’s health and well-­being. Failing to address the structural obstacles to participation can only deepen inequalities between older people, and these inequalities reflect a lifetime of inequalities based on gender and class.4 Until there is a shift from focusing on needs and social costs to researching what older people do, studies of the intersections of age and gender that do not reproduce age and gender stereotypes will remain scarce. It is only by analysing how gender and class shape what older people are enabled to do, under what circumstances and with what consequences for themselves and others, that research can go beyond discourses that contribute to the stigmatization of older people.5

CONFRONTING STEREOTYPICAL DISCOURSE IN INDIA In India health and health related research on old age also typically focuses on mental health, frailty and disability, food poverty and, more recently, on non-­contagious diseases.

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Health, later life and gender  ­153 The similarity of concerns with research on later life in Britain is not surprising as the social scientists who gained prominence in India were trained in the United States in the 1940–1950s and attempted to relocate theories in sociology, psychology and social work to an India facing the effects of rural to urban migration, the fragmentation of refugee families resulting from the Partition of India (into India and Pakistan) at Independence, and industrial employment practices (Sivaramakrishnan, 2014).6 Applying their expertise they defined these experiences as generators of ‘psychosocial’ tensions that could bring on and accelerate symptoms of ageing and senility. Just prior to Independence, key texts by Indian experts in disciplines new to India produced foundational myths of traditional India, two of which stand out for their impact on contemporary approaches to old age. First, a debate about labour reform and welfare provision for industrial workers resulted in the colonial appointment of the Labour Investigation Committee led by the economist B.P. Adarkar who continued to advise government on social insurance after Independence. Adarkar observed the economically active age groups in Indian industry to be between 15 and 55 years and that older workers could fall back on extended family support in the villages when no longer able to work. He defined premature death as a more serious policy issue than old age and asserted that old age pensions were not a priority because ‘every contingency could not be addressed’ (Sivaramakrishnan, 2014: 974). Second is J.M. Kumarappa, who later headed the Bombay School of Social Work and was influential with Indian nationalist leaders. He wrote movingly on the ‘new poor’ dependent on beggary in India’s towns and cities. He posited that the cause lay in broken working-­class families due to rapid changes in social life, rural–urban migration and the erosion of family networks that resulted in the new social evils of family neglect and immorality, leaving mothers vulnerable, children delinquent and the old destitute. The die was cast by Jawaharlal Nehru, India first Prime Minister, who when enumerating the social groups comprising the country’s social priorities identified children as having a ‘first claim on us, because they represent the India of Tomorrow’; women were associated with an ‘inspiring’ history and tradition and needed to play a full part in the life of the nation; on older people he was silent (Sivaramakrishnan, 2014: 974). The legacy of this period has been the near total exclusion of older people from state provision and purview. It was only in 1995 that the government of India began to provide old age pensions for ‘the destitute’, that is, those below the poverty line without any means of support, including no surviving adult son. The meanness of the sum allocated and the coverage of only 50 per cent of those eligible for a pension (Alam, 2006: 230) continued the Nehruvian view that older people are irrelevant to India’s development.7 This exclusion of older people from state purview is also visible in the National Family Health Surveys (NFHS) that inform health and social policy. The NFHS have age cut-­ offs of 49 for women and 54 for men. The thrust of India’s policy towards older people is also visible in the national policy on older people, the first of which was launched in 1999 in response to a United Nations (UN) General Assembly Resolution, and later versions that were also in response to further UN adoptions, including MIPAA. These policies have produced little beyond some concessions to middle-­class older people in terms of bank interest, tax and travel concessions. The main outcome of the policy has been the Maintenance and Welfare of Parents and Senior Citizens Act, 2007, that brought together under one Act extant provisions in prior Acts requiring adult sons to support their parents. The new development was to extend this to all adult children and

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154  Handbook on gender and health ­ re-­mortem heirs, to enable older people to take cases to local-­level courts, and to enable p the courts to commit those who fail to support older people to up to three months’ imprisonment. The point, and certainly the main achievement of this Act, coming as it did after 12 years of the social pension, was to reassert that families and heirs are responsible for older people, not the state. In contrast to this discourse of a tradition of family support are watercolours and photographs from the early and late nineteenth century that depict people working into late old age, some in multigenerational contexts, some not. Similarly, survey data from the nineteenth century demonstrate that joint families, in which older parents live together with younger married children, were not more prevalent in the past (Shah, 1996). The degree to which the discourse of traditional filial support has been bracketed off from the known realities of waves of conquest and of class and caste relations (Habib, 2002) is striking; the poverty endured by those lower down the social hierarchy would not have allowed unproductive dependants. However, this creation of a mythical past is not new, as noted by Shah (1996), and also by Sivaramakrishnan (2014: 978): ‘the device of judging and reforming the present by making up a singular, traditional past when Indian family ties and social relations had been untouched by the onset of modernity was not new. It had already been the subject of middle class writings in the colonial period’. The dominance of this discourse of the traditional past in contemporary discussions of older people’s health and well-­being is amply demonstrated by the work of one of India’s leading social gerontologists, Irudaya Rajan. Together with Sanjay Kumar, in 2003, Rajan wrote an article, entitled ‘Living arrangements among Indian elderly’, for the peer-­reviewed journal Economic and Political Weekly which is a key source for anyone researching India and for Indian policy-makers. The six-­page article was based on an analysis of the 1992–1993 National Family Health Survey, examining the extent to which older people are co-­residing with their children; the argument being that older people’s economic security is a ‘major issue’ if they are not co-­resident. Setting aside the authors’ presumption of economic dependence, this article produced the valuable finding that 88 per cent of older people co-­reside with children and grandchildren, many households accommodate more distant elderly relatives (in-­laws, aunts and uncles), 6.6 per cent of older people live as a couple, and 2.4 per cent of older people live alone; 3.5 per cent of older women live alone. The conclusion to the article was that the evidence ‘reinforces the conventional notion that the family is still taking care of the elderly in a big way’ (2003: 80). This is the conventional argument put forward for not providing a universal state pension: families support the old. For our purposes this article is significant in two respects. First, it shows that the often-­repeated public discourse of failing family values is not supported by patterns of co-­residence. Second, it shows that peer-­reviewed articles on Indian gerontology end up reproducing the dominant discourse on failing family values, despite the article’s evidence and main argument; whether that is the outcome of peer review is not possible to determine. The article begins with a lengthy paragraph stating that the ‘caring of the elderly by family members . . . has been a practice down the ages’ (2003: 75), and that rising longevity, lowered fertility, increasing female labour force participation, age selective rural–urban migration, ‘the spread of western culture and lifestyle, and growing individualism, among other factors have had their impact on the traditional family system’ (2003: 75). The overall policy conclusion is that ‘a suitable policy measure needs to be

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Health, later life and gender  ­155 framed towards restoring familial care for the elderly in the unavoidable circumstances of drastic society changes in the wake of modernisation’ (2003: 80), despite the lack of direct evidence on care in the data set to support such a conclusion. And while the authors do make a one-­sentence statement that pensions are required (2003: 80), and that co-­ residence is no guarantee of care and financial support (2003: 75), the effect of the more extensive framing of the analysis within a discourse that goes back at least to the 1940s, just prior to Independence, is to let India off the social welfare hook; older people are living with relatives and those that are not should be.8 By relegating the support of older people to the family in a context of 93 per cent of people working in low-­paid insecure work and between 30–70 per cent of people below the poverty line,9 it is clear that the state is placing them in competition with other generations for very limited household resources. As stated earlier, there is little direct evidence of older people’s health in India as the country regularly samples only the health of children, women to the age of 49, and men to the age of 54. However, as a country with more stunted children than the whole of sub-­Saharan Africa and with high rates of anaemia amongst women up to age 49 (56 per cent in 2005–2006), which is positively correlated with lower wealth status (Balarajan et al., 2013), it is extremely likely that a large proportion of people aged 60 endure a significant degree of poverty-­related health outcomes, as well as the non-­communicable diseases widely understood to be age-­related. Research on inequalities in food consumption undertaken in rural India in 2009–2010 found that the bottom 20 per cent of the monthly per capita expenditure quintiles ate an average 33 kg of food (all food groups), while the top quintile ate an average of 50 kg (Gupta and Mishra, 2014), and that suggests the likelihood of the poor nutritional status of older people. This extrapolation is supported by a small study of active middle-­aged and older villagers in northern India that found 40 per cent had a body mass index (BMI) as low as 18.5 per cent (PHRN-­Pension Parishad, 2013); a four-­village study in South India of villagers aged 60 and over found that nearly 50 per cent had a BMI of 18 per cent and 53 per cent had anaemia (Purty et al., 2005); and a further rural study in South India that found 63 per cent of people aged 60 or more were malnourished or at risk of malnourishment, while 60 per cent had deficient protein energy intake (Vedantam et al., 2010). Taken together these data demonstrate that for a large section of the population families cannot provide adequate support for anybody, irrespective of age and gender. In terms of gender differentials, there is evidence from the Census of India’s National Sample Survey (NSS) data for 2007–2008 that reveals differences: men over 60 do receive more food than women over 60, but the most significant difference is to be found in health expenditure where, in a country with one of the highest rates for out-­of-­pocket expenses, 85 per cent of household expenditure on people over 60 is spent on men, though the expenditure on elderly health care is not even 1 per cent of the total household expenditure (Maharana and Ladusingh, 2014). This research found that older people received less than one-­tenth of total household food expenditure and that household expenditure on education had risen from 0.3 per cent to 6 per cent between 1999–2000 and 2007–2008. This evidence on family resource distribution suggests that the central issue for older people is not so much gender differentials but inadequate social provision, which families are trying to compensate for in the context of a vicious labour market, including by directing family resources towards the youngest generation in the hope of a better future. In such a context it is necessary to explore not just what older people receive from

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156  Handbook on gender and health families but how they support families. The 2004–2005 NSS revealed that 38 per cent of people aged 60 and over are working and that they represent 7 per cent of the workforce, which at the time was approximately their percentage in the population (Selvaraj et al., 2011). However, as many older women are not recognized as workers in family businesses, despite putting in many hours of work (being categorized, instead, as ‘passing time’ or merely ‘helping out’), it is unlikely that they would have been enumerated as working, making the figure of 38 per cent working an underestimate. Research undertaken by myself and colleagues in five of Chennai’s slum settlements between 2007–2010 and 2012–2013 with an 800-­household survey and 179 household semi-­structured interviews as well as observation of street vendors in one busy street market revealed that older people were engaged in more than 40 occupations, reflecting the specificities of local economic opportunities.10 Yet this did not represent the wide range of activities that older people could be seen engaged in across Chennai, so we undertook what might be called a convenience-­based photo survey of older people that the research team came across in the city over the life of the project. The research revealed that the older urban poor are engaged in every sector of the urban economy, including financial services, manufacturing, construction, transport, retail and services, as well as the delivery of international development initiatives (Vera-­Sanso, 2012). It found that older people play an essential economic role as a reserve army of labour, filling the economic niches no longer filled by younger people, due to the reduction in child labour, the rise in school enrolments or the movement of young people into more modern work contexts. The result is an age-­and sex-­segregated labour force where, for instance, older people are concentrated in street vending and younger people work in shopping malls and department stores, where cycle rickshaw pullers are old men and taxi drivers are young men, where young men earn 50 per cent more than older men and where men aged over 40 find it increasingly difficult to secure work because of a large youth population (to age 29) seeking work.11 In this context of age discrimination in male employment, households have to push more people into the workforce. In the 800 households surveyed only 2 per cent of children aged 10–14 were working, reflecting the widespread acceptance of education in this part of India. Consequently, women began to take up work from the age of 30, in response to the declining incomes of their older spouses. These women relied on older women to take on their care and domestic work. While most relied on relatives, including relatives not living in their household, others paid older women to cover time-­consuming tasks such as waiting in line to collect water from water lorries. Once drawn into work women tend to stay in work, though that work may change: some older women took on more domestic and caring roles, some work in family businesses, though often defined as ‘passing time’ or ‘helping’, and some went into paid or own-­account work. The outcome of age discrimination in male employment was a switch to increasing involvement in work for younger women, the extending of paid and unpaid work for older women, often into deep old age, and a declining capacity to earn for middle-­aged and older men. It is the intersection between the informal economy and the huge shortfalls in state provision of social and physical infrastructure that determines older people’s health in India. Caught in the informal economy, without job or income security, holiday or sickness pay, and no social pension worthy of the name, the vast majority of people living on low incomes are forced to work as much as they can. The Chennai research found that most people, including older people, work 6–7 days a week. In some trades, such as

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Health, later life and gender  ­157 vending, older women could be working 78 hours a week, setting out for the wholesale market at 4 am and finishing work after 9 pm. Low incomes, lack of work security and welfare provision, under-­resourced and often distant and poor-­quality public medical services, and poor education provision (which forces families into low-­quality private education) all work to ensure that older people cannot afford to take time off to access state health provision or to convalesce.12 As one 72-­year-­old female vendor, who supports her widowed and disabled son and his children, succinctly put it, ‘If I have the cataract operation I need a month to recover – who will feed my grandchildren and pay for their school fees?’. Consequently older workers have the choice of private health care or doing without the care they need, many merely describing their symptoms at a pharmacy. Medicines that are not obtained from public institutions are unaffordable, giving people the choice of repeated loss of income, as hospitals dole out medicines on a per diem basis (Ergler et al., 2011), or selecting the cheaper elements from a prescription, or pharmacy recommendation, which will allow them to continue working. The outcome is reliance on painkillers and the sporadic use of antibiotics and other medicines. It is not just older people earning an income who are not having their health needs met. Anyone in a low-­income household who needs to be cared for at home or in a public hospital (where nursing and food are not provided) jeopardizes the livelihoods of family members working in the informal economy as they have no right to time off. This level of precariousness forces family members, particularly older people, to forego necessary medical care and medication on the basis of direct costs and potential livelihood impacts. For example, a study of all older people in one of Chennai’s slums found that 40 per cent of older people’s illnesses were not treated despite the proximity of public and private health facilities (Balagopal, 2009). Economic precariousness exposes older people to the health impacts of long-­term poverty and of global economic turbulence. Surveys of household income undertaken in the five Chennai slums studied, covering November 2007 to May 2009, found that the global financial crisis, global food price hikes and climate shocks had cascaded down to the settlements studied, forcing families to cut steeply into their food consumption, shedding protein and vegetables and in some cases dropping to one meal a day, while increasing their hours of work (Harriss-­White et al., 2013).13 By May 2009 people reported some improving food consumption. In autumn 2012, we returned to the settlements to uncover what advantage a pension increase from Rs400 per month to Rs1000 per month ($7.50 to $18.80) had for the people lucky enough to have secured a pension. We found that the increased pension had not released older people from the need to work, but they did report an easing of uncertainty. They knew that there would be enough rice for two-­thirds of the month, or they could buy more of the medicines they needed, and the self-­employed could take a day or two off work per month when sick. However, this did not extend to enabling them to access public health facilities if they were sick enough, or distant enough, to require help from a working relative. The reason why the sizeable pension increase of 2011 (in percentage terms) did not do more for older people is that the pension, which had last been raised in 2007, had been allowed to depreciate significantly. Unfortunately, at the time of writing in the summer of 2015, the pension in Tamil Nadu, which is one of the most generous in the country, remains unchanged since April 2011 at Rs1000 per month. Far from confronting significant hardship, in India the contemporary thrust in social

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158  Handbook on gender and health provision and urban planning is sharply against reducing inequalities in livelihoods and in access to state resources. Instead welfare measures, such as the non-­contributory pension, food security provisions and workfare programmes are being reduced, stalled or poorly implemented. Urban planning has progressed from the ‘Slum Free Cities’ programme of slum demolition and resettlement at significant distances from the city (30 km in Chennai’s case) with deeply inadequate infrastructure, transport, educational, medical provision or work opportunities (Coelho et al., 2012), to the ‘100 Smart Cities’ programme, the promotion of which is notably silent on poverty and inequality, which is producing yet again ‘islands of California in a sea of sub-­Saharan Africa’ (Dreze and Sen, 2013: ix). Plans to double public spending on health from 1 per cent of gross domestic product (GDP) to 2 per cent were put on hold in 2015. New contributory schemes for pensions for people in the unorganized sector and for farmers are now being introduced, as are disability insurance and life insurance. These measures will not help the vast number of people who are not earning enough to eat regular meals, who are not employed regularly and without sufficiently generous incomes to make contributions to pension and insurance schemes. They are less likely to be taken up by women and especially middle-­aged women who face age and gender discrimination and may well be the only or main income earner in the household. Nor do these measures recognize the importance of preventive medicine and health promotion over curative medical care; the importance of food, water, shelter, sanitation, education and other basic needs (Narayan, 2011). As Sengupta and Prasad (2011: 15) argue, ‘the current framework of economic growth is not designed to address the concerns of very large sections of the population, for whom it has directly perpetuated the situation of ill health and inadequate health care’. This brings the discourse on filial support of older people into perspective. By framing Indian tradition as one of family support for frail, old, dependent persons within an undifferentiated past, the discourse delegitimates questions regarding social inequality and the capacity of all families to support or look after older people now (or in the past). By overlooking the necessity of older people to undertake paid and unpaid work to support their families, the discourse enables India to turn a blind eye to older people working long hours into deep old age while benefiting from an enlarged, low-­cost labour force. By defining care and support as happening within the family, the need for social infrastructure becomes secondary to stigmatizing families that cannot support older people and pulls the inadequacies of physical infrastructure out of the frame.

CONCLUSION This chapter has made four arguments. First, public pronouncements on what older people are, do and need should be examined as discourses, as attempts to structure ways of thinking. In the United Kingdom the Alzheimer’s Society’s presentation of data on older people, which was aimed at raising the profile of the disease, served to erroneously heighten the association of old age with dementia and presented older people as an unaffordable burden on society. Defining older people’s care as publically insupportable or intergenerationally unjust is a necessary step in legitimating a reduction in public support. In India the discourse of traditional filial support for older people and of children as having the first call on national resources has enabled the government to

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Health, later life and gender  ­159 avoid getting caught in provision for older people beyond a thin tokenism. Second, these discourses present older people as frail, dependent and vulnerable, overlooking the significant contributions older people make to family, community and economy through their volunteering, unpaid family work and paid work. Third, the evidence base of what older people do, rather than what they need, remains underdeveloped, and until we shake off stereotypical assumptions of what should be studied in relation to older people we cannot provide an adequate analysis of the intersection of age, gender and class. Fourth, health and access to health care need to be understood from a much wider perspective than health care provision; determining factors range from vulnerabilities in the labour market to social and physical infrastructure provision, and this is as true for older people as younger ones. Despite the unlikely comparison of older people in the United Kingdom and in India’s slums, we can see that older people in both contexts are vital, yet widely overlooked, contributors to national economies through both their paid and unpaid work. Most face ageism and age discrimination to some degree but those whose situation is most difficult, older people living in India’s slums, suffer the multiple deprivations of income insecurity and inadequate state provision of social infrastructure (health, pensions and education) and physical infrastructure (water, sanitation, storm water drainage). Their families, who are caught in equally precarious arrangements that bear down on their health and survival, are as likely to need older people’s help, both financial and physical, as they are to provide it. The solution to a poverty that combines stigmatization, marginalization and being overlooked with economic insecurity and health deficits lies in recognizing that ‘poverty persists because the concerns of poor people are (kept) invisible and their needs unpoliticized’ (Mosse, 2010: 1165), thereby enabling poverty and its consequences to appear unexceptional, even normal (Gupta, 2012). We need to recognize that ageist assumptions regarding older people’s dependency and the younger generation’s capacity not only misconstrues the reality, and mutuality, of lives (especially those lived in precarious conditions) but also entirely misses the degree to which national economies are dependent on the paid and unpaid labour of older people, a realization that would help to upend stigmatizing discourses. If we fail to tackle ageism in research design, studies of the intersection of age and gender can only serve to reinforce the stigmatizing discourse of burdensome, vulnerable and isolated elderly women and men.

NOTES  1. See Vera-­Sanso (2010) on gender and the accumulation of advantage and disadvantage over the life course.   2. Five per cent of people with dementia are aged under 65, and 7 per cent of people aged 65 and over have dementia (Prince et al., 2014).   3. When the report was published in 2004, the National Minimum Wage required that those aged 21 and over were paid £6.50 per hour.  4. See, for example, the Office for National Statistics (2014) on the social gradient in morbidities; for example taking two boroughs in London, Richmond, noted for its privileged residents, and Newham, noted for its disadvantaged residents, the men and women in Richmond on average enjoy over 12 per cent more of their life disability-­free by comparison to men and women in Newham. In both areas men spend 2 per cent more of their life disability-­free by comparison to women. Similarly national evidence on income gaps in later life shows men’s incomes to be 70 per cent higher than women’s (Arber, 2015).

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160  Handbook on gender and health   5. For a sample of the few examples of a gender analysis of what older people do in the United Kingdom, see Arber and Ginn (1990), Arber and Timonen (2012) and Gray (2009).   6. I am grateful to Sivaramakrishnan’s work for making visible the historical roots to much contemporary discourse on formal sector retirement, which until recently started at age 55, as well as discourses on senility and the traditionality of family support.   7. The national social pension was launched under the Ministry of Rural Development in 1995 for those aged 65 and over, living below the poverty line, who have no means of support, do not beg and have no surviving adult son. Budget allocations did not support every older person eligible, so in 2000 those not covered by the pension became eligible for the Annapurna Yojana scheme of 10 kg of free rice. In 2007 the surviving son bar was removed and the pension was raised from Rs75 to Rs200 a month, and has not since been raised despite an average inflation rate of 10 per cent. In 2011 the eligibility age dropped to 60 years and pensions for people aged over 80 was raised to Rs500 per month. In 2015, in the State of Tamil Nadu, the surviving son bar was reintroduced.  8. By comparison to the low-­income countries of Bangladesh and Nepal which put 0.08 per cent and 0.32 per cent of GDP, respectively, into social pensions, India, a lower-­middle income country, puts only 0.03 per cent into social pensions (pension-­watch.net).   9. The official government poverty line places 29 per cent below the poverty line; the World Bank definition of less than US1.25 purchasing power parity places 42 per cent below the poverty line; a Multi-­ dimensional Poverty Index includes 55 per cent of people (Horton and Das, 2011). A $2 a day poverty line would include 70 per cent of people. 10. The 2007-­2010 project ‘Ageing, Poverty and Neoliberalism in Urban South India’ (RES-­352-­25-­0027), was part of the Arts and Humanities Research Council (AHRC)/ Biotechnology and Biological Sciences Research Council (BBSRC)/ Engineering and Physical Sciences Research Council (EPSRC)/ Economic and Social Research Council (ESRC)/ Medical Research Council (MRC) ‘New Dynamics of Ageing’ research programme (2005–2013). The research team were: P. Vera-­ Sanso (principal investigator), V. Suresh, M. Hussain, H. Joe, A. George and B. Harriss-­White. The 2012–2013 ‘Ageing and Poverty: The Working Lives of Older People in India’ ESRC Follow-­on Funding (ES/J020788/1). The research team were: Penny Vera-­Sanso (principal investigator), V. Suresh, M. Hussain, S. Priya and J. Longina. 11. In order to demonstrate the wider relevance of research in the context of negligible research on older workers and in order to garner a better idea of the extent of older people’s work across India we launched a national photo competition with The Hindu, one of India’s most widely read newspapers. This produced nearly 3000 photographs of older people working across the country, virtually all in the informal economy (The Hindu, 2013). The photographic competition demonstrated that older people are engaged in a huge range of work from farming, salt-­panning, brick-­making and cotton-­picking to carpentry, vending, guiding Himalayan tourists and railway track inspecting. The research project’s approach has been to trace the forward and backward linkages of older people’s work. If we apply that approach to the work of the older track inspectors whose dangerous, arduous and isolated work younger people are unwilling to take up, we cannot avoid seeing how critical older people’s work is. The Indian Railway, whose revenue in 2013–2014 was $23 billion, as India’s largest employer and biggest consumer and transporter – is absolutely critical to India’s economy – and is dependent on men inspecting railway tracks at ages well beyond retirement age in order to ensure the continued functioning and safety of the network. 12. See Ergler et al. (2011) for the factors determining whether Chennai’s poorer residents select private health over public health services. 13. Research undertaken in Delhi slums between 2011 and 2012 identified similar strategies to cope with food insecurity (Gupta et al., 2015).

REFERENCES Alam, M. (2006) Ageing in India: Socio-­economic and Health Dimensions, New Delhi: Academic Foundation. Arber, S. (2015) Stark inequalities in ageing as UK government encourages people to work longer. Science Daily, 25 February. http://www.sciencedaily.com/releases/2015/02/150225102843.htm, accessed 20 July 2015. Arber, S. and J. Ginn (1990) The meaning of informal care: gender and the contribution of elderly people. Ageing and Society, 10(4): 429–454. Arber, S. and V. Timonen (eds) (2012) Contemporary Grandparenting: Changing Family Relationships in Global Contexts, Bristol: Policy Press. Balagopal, G. (2009) Access to health care among poor elderly women in India: how far do policies respond to women’s realities?. Special Issue (eds) P. Vera-­Sanso and C. Sweetman, Gender and Development, 17(3): 481–492.

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Health, later life and gender  ­161 Balarajan, Y.S., W.W. Fawzi and S.V. Subramanian (2013) Changing patterns of social inequalities in anaemia among women in India: cross-­sectional study using nationally representative data. British Medical Journal, 3(3). http://bmjopen.bmj.com/content/3/3/e002233.full. Bloom, D., D. Canning and A. Lubet (2015) Global population aging: facts, challenges, solutions and perspectives. Daedalus, 144(2): 80–92. Carers UK (2014) Facts about carers. Policy Briefing, May. http://www.carersuk.org/for-­professionals/policy/ policy-­library/facts-­about-­carers-­2014, accessed 7 August 2015. Carers UK and Age UK (2015) Caring into later life: the growing pressure on older carers. http://www.carersuk. org/for-­professionals/policy/policy-­library/caring-­into-­later-­life, accessed 7 August 2015. Coelho, Karen, T. Venkat and R. Chandrika (2012) The spatial reproduction of urban poverty: labour and livelihoods in a slum resettlement colony. Economic and Political Weekly (Review of Urban Affairs), 47(47–48): 53–63. Dobson, C. and M. Dobson (2014) Don’t despair: dementia will be cured. The Telegraph, 25 May. Dreze, J. and A. Sen (2013) An Uncertain Glory: India and its Contradictions, Princeton, NJ: Princeton University Press. Ergler, R., P. Sakdapolrak, H-­G. Bohle and R. Kearns (2011) Entitlements to health care: why is there a preference for private facilities among poorer residents of Chennai, India?. Social Science and Medicine, 72: 327–337. Global Health Observatory (GHO) (2015) Data Repository. World Health Organization. http://apps.who.int/ gho/data/view.main.690?lang=en, accessed 4 July 2015. Gray, A. (2009) The Changing availability of grandparents as carers and its implications for childcare policy in the UK. Journal of Social Policy, 34(4): 557–577. Gupta, A. (2012) Red Tape: Bureaucracy, Structural Violence, and Poverty in India, Durham, NC: Duke University Press. Gupta, A. and D. Mishra (2014) Food consumption pattern in rural India: a regional perspective. Journal of Economic and Social Development, 10(1): 1–16. Gupta, P., K. Singh, V. Set, S. Agarwal and P. Mathur (2015) Coping strategies adopted by households to prevent food insecurity in urban slums of Delhi, India, Journal of Food Security, 3(1): 6–10. Habib, I. (2002) Essays in Indian History: Towards a Marxist Perception, London: Anthem Press. Harriss-­White, B., W. Olsen, P. Vera-­Sanso and V. Suresh (2013) Multiple shocks and slum household economies in South India. Special Issue (eds) S. Corbridge and A. Shah, Economy and Society, 42(3): 398–429. Higgs, P., M. Hyde, R. Wiggins and David Blane (2003) Researching quality of life in early old age: the ­importance of the sociological dimension. Social Policy and Administration, 37(3): 239–252. Katz, S. (1996) Disciplining Old Age: The Formation of Gerontological Knowledge, Carlottsville, VA, USA and London, UK: University of Virginia Press. Maharana, B. and L. Ladusingh (2014) Gender disparity in health and food expenditure in India among the elderly. International Journal of Population Research, ID 150105. Mosse, D. (2010) A relational approach to durable poverty, inequality and power. Journal of Development Studies, 46(7): 1156–1178. Narayan, R. (2011) Universal health care in India: missing core determinants. The Lancet, January: 13–14. National Council for Voluntary Organisations (NVCO) (2015) UK Civil Society Alamanac 2015: volunteer profiles. London: NVCO. http://data.ncvo.org.uk/a/almanac15/volunteer-­profiles/, accessed 11 November 2014. Office for National Statistics (2011) 2011 Census: population estimates for the United Kingdom. 27 March. http://www.ons.gov.uk/ons/rel/census/2011-­census/population-­and-­household-­estimates-­for-­the-­united-­ kingdom/stb-­2011-­census-­-­population-­estimates-­for-­the-­united-­kingdom.html, accessed 7 August 2015. 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162  Handbook on gender and health Purty, A.J., J. Bazroy, M. Kar, K. Vasudevan, A. Veliath and P. Panda (2005) Morbidity pattern among the elderly population in the rural area of Tamil Nadu, India. Turkish Journal Medical Science, 36: 45–50. Quadagno, J. (1989) Generational equity and politics of the welfare state. Politics and Society, 17: 353–376. Rajan, S.I. and S. Kumar (2003) Living arrangements among Indian elderly: new evidence from National Family Health Survey. Economic and Political Weekly, 38(1): 75–80. Selvaraj, S., A. Karan and S. Madheswaran (2011) Elderly workforce participation, wage differentials and contribution to household income, building knowledge base on population. UNFPA Working Paper 4. http:// www.isec.ac.in/BKPAI%20Working%20paper%204.pdf, accessed 7 August 2015. Sengupta, A. and V. Prasad (2011) Towards as truly universal Indian health system. The Lancet, January: 15–16. Shah, A.M. (1996) Is the joint household disintegrating?. Economic and Political Weekly, 31(9): 537–542. Sivaramakrishnan, K. (2014) Aging and dependency in an independent Indian nation: migration families, workers and social experts (1940–60). Journal of Social History, 47(4): 968–993. Tan, J.P., A. Buchanan, E. Flouri, S. Attar-­ Schwartz and J. Griggs (2010) Filling the parenting gap? Grandparent involvement with UK adolescents. Journal of Family Issues, 31(7): 992–1015. Thane, P. (ed.) (2005) The Long History of Old Age, London: Thames & Hudson. The Hindu (2013) National photo context on ‘The Working Elderly’. http://bit.ly/19Y6jqp, accessed 11 November 2014. United Nations (UN) (2002) Political Declaration and Madrid International Plan of Action on Ageing. Second World Assembly on Ageing, Madrid, Spain, 8–12 April, New York: United Nations. Vedantam, A., V. Subramanian, N.V. Rao and K.R. John (2010) Malnutrition in free-­living elderly in rural south India: prevalence and risk factors. Public Health Nutrition, 9: 1328–1332. Vera-­Sanso, P. (2010) Gender and ageing in India: conceptual and policy issues. In Sylvia Chant (ed.), Elgar International Handbook on Gender and Poverty, Cheltenham, UK and Northampton, MA, USA: Edward Elgar Publishing. Vera-­Sanso, P. (2012) Gender, poverty and old age, in urban south India in an era of globalisation. Oxford Development Studies, 40(3), 324–340. Vera-­Sanso, P., A. Barrientos, L. Damodaran, K. Gilhooly, A. Goulding, C. Hennessy, R. Means, M. Murray, A. Newman, W. Olphert, P. Tew, J.L. Thompson, C. Victor and N. Walford (2014) Participation and social connectivity. In A. Walker (ed.), The New Dynamics of Ageing, Bristol: Policy Press. Vincent, J. (1999) Who’s afraid of an ageing population? Nationalism and the free market and the construction of old age as an issue. Critical Social Policy, 16: 3–26. Vincent, J. (2006) Ageing contested: anti-­ageing science and the cultural construction of old age. Sociology, 40(4): 681–698. Walker, A. (1990) The economic ‘burden’ of ageing and the prospect of intergenerational conflict, ageing and society. 10(4): 377–396. Walker, A. (2014) A new policy perspective on ageing. In Alan Walker (ed.), The New Science of Ageing, Bristol: Policy Press. Wheelock, J., E. Oughton and S. Baines (2003) Getting by with a little help from your family: toward a policy-­ relevant model of the household. Feminist Economics, 9(1): 19–45. World Health Organization (WHO) (2002) Active Ageing: A Policy Framework, Geneva: WHO, http://apps. who.int/iris/bitstream/10665/67215/1/WHO_NMH_NPH_02.8.pdf, accessed 4 July 2015. World Health Organization (WHO) (2004) World Health Report 2004 Annexes by Country. http://www.who. int/whr/2004/annex/country/en/, accessed 4 July 2015.

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PART III GENDER, WORK AND HEALTH

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10.  Gender, work and health: a step forward in women’s occupational health Lucía Artazcoz, Imma Cortès-­Franch and Vicenta Escribà-­Agüir

INTRODUCTION Although women entered the labour market decades ago, gender inequalities in work still persist and are one of the main sources of gender inequalities in health. Understanding work-­related gender inequalities in health requires integrating: (1) the gender-­based division of work; (2) the gender roles and norms; and (3) the gender inequalities in power and access to and control over resources. In almost all societies, women and men perform different activities, although the nature and range of these activities vary across classes and across communities. Women are typically responsible for childcare and household work whereas men are typically expected to have a job and to be responsible for meeting the household’s needs for food and resources. As a result of the gender division of society, on average, women participate less in the labour market than men, whereas they assume the largest share of unpaid work in the household. Women workers also tend to be less well paid than men, and they occupy jobs with lower job security, fewer prospects of advancement and less responsibility. In all societies, males and females are expected to behave in ways that are very different. They are socialized from early childhood to conform to masculine and feminine roles and norms. Though the shape of masculinity may vary between communities, the development and maintenance of a heterosexual male identity usually requires the taking of risks that are seriously hazardous to health. As a result many men also feel compelled to engage in risky behaviour in order to prove their masculinity (Courtenay and Keeling, 2000; Cameron and Bernardes, 1998). Having greater access to and control over resources makes men more powerful than women in any social group. Male power and control over resources and decisions is institutionalized through the laws and policies of the state, and through the rules and regulations of formal social institutions. Finally, understanding gender inequalities in health requires biological differences to be taken into account. Two parallel approaches have dominated the research on work and health. On one hand, classical occupational health has focused on job safety and hygiene hazards prioritizing the study of male worker populations where their prevalence is typically higher. On the other hand, social epidemiology has considered work as a social determinant of health or as a proxy of socio-­economic status. Traditional occupational health has focused on job hazards typical of male occupations and the interest in women’s occupational health has often been limited to reproductive hazards. On the other hand, the examination of work as a determinant of health has used different conceptual frameworks depending on gender. Whereas among men research has been primarily focused on employment and 165 Jasmine Gideon - 9781784710859 Downloaded from Elgar Online at 11/03/2017 02:47:53AM via Sydney University

166  Handbook on gender and health working conditions as well as on social class inequalities, with occupation considered as a proxy of social class, research among women has been dominated by the role framework, emphasizing women’s roles as housewives and mothers with paid employment seen as an additional role (Artazcoz et al., 2007a). Both approaches are consistent with the genderdivision of work that permeates all levels and spheres of society, even epidemiological research. Moreover, there is also a gender division of work both in the labour market and in the domestic sphere (Charles, 2011; Messing and Ostlin, 2006). The analysis of work-­related gender inequalities in health should consider the intersection with other axes of inequalities such as social class or ethnicity (Artazcoz et al., 2007a). The term ‘intersectionality’ has come to be widely used in studies of gender, signalling that we are likely to observe complex interactions of gender, class, race and other dimensions of inequality in contemporary societies, which combine in non-­additive ways (Shields, 2008; Choo and Ferree, 2010). Moreover, the intersection of gender and the welfare state typologies, which determine differences on the genderdivision of work, has been reported (Korpi et al., 2013; Iversen and Rosenbluth, 2006; Orloff, 1993; ­Pfau-­Effinger, 2005). The objective of this chapter is to analyse work-­related gender inequalities in health in a conceptual framework which includes the following key elements: (1) the gender division of work; (2) work, both paid and domestic work, as a source of exposure to health hazards and as a social determinant of health; (3) the differences related to sex and to gender; (4) the intersection of gender with social class; and (5) the role of welfare state regimes in shaping gender differences in the role of work as a social determinant of health. The analysis refers to the situation in developed countries, primarily European countries.

GENDER SEGREGATION IN THE LABOUR MARKET According to the gender division of work, labour force participation is lower among women, but rates differ considerably between countries, those with more conservative family and gender policies, such as Mediterranean countries, having lower activity rates and a significant proportion of women working as full-­time homemakers. Conversely, Nordic countries that promote double earner, double carer models with generous public resources for caring for children have the lowest gender differences in labour force participation (Table 10.1). Moreover, although the labour force participation of women, and especially of married women, has increased steadily, a high proportion of them work part-­time, once again with significant differences between countries (Table 10.2). In all European countries, the proportion of women working part-­time is higher than that of men. Whereas the Netherlands has the highest proportion of men and women working ­part-­time – with almost 80 per cent of women in part-­time jobs – proportions are much lower in Southern European countries and Eastern European countries. Moreover, it should be noted that for many workers, part-­time work is an involuntary option that has increased during the financial crisis. For example, according to the Labour Force Survey (LFS), during the period 2002–2013 the proportion of involuntary part-­time work among women from countries more affected by the crisis increased from 20.5  per  cent to 60.8 per cent in

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A step forward in women’s occupational health  ­167 Table 10.1  Labour force participation in Europe by country and sex, 2013 (per cent)

EU-­27 Austria Belgium Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Iceland Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Switzerland United Kingdom

Men

Women

Difference

64.6 67.6 59.7 59.7 50.3 70.2 68.1 66.2 68.4 63.0 61.7 66.3 62.0 60.7 83.7 67.7 58.9 66.1 64.1 66.3 66.6 71.1 73.7 64.4 66.2 63.8 68.1 63.1 65.4 68.1 75.1 69.0

51.2 55.7 47.8 48.6 38.3 57.1 50.9 58.6 55.4 55.5 51.8 54.6 44.1 45.3 77.6 53.0 39.7 54.0 52.9 52.5 38.8 59.4 68.3 48.2 54.8 47.0 51.0 51.6 52.7 60.5 61.9 56.9

13.4 11.9 11.9 11.1 12 13.1 17.2 7.6 13.0 7.5 9.9 11.7 17.9 15.4 6.1 14.7 19.2 12.1 11.2 13.8 27.8 11.7 5.4 16.2 11.4 16.8 17.1 11.5 12.7 7.6 13.2 12.1

Source:  Eurostat, Labour Force Survey, April 2014.

Spain, from 32.2 per cent to 58.6 per cent in Italy, from 30.4 per cent to 53.3 per cent in Portugal, and from 49.3 per cent to 66.7 per cent in Greece. The corresponding figures for men are 21.1 per cent to 70.1 per cent in Spain, 50.0 per cent to 76.7 per cent in Italy, 28.9 per cent to 43.1 per cent in Portugal, and 63.6 per cent to 70.7 per cent in Greece. Most studies have shown that part-­timers usually earn less per hour than full-­timers, even after controlling for education, experience and other relevant factors. Part-­time work in Europe is often associated with marginal employment in low-­paid, low-­status jobs such as sales, catering and cleaning. However, whereas there are countries where the use of part-­timers represents a marginalization strategy that provides employers with a

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168  Handbook on gender and health Table 10.2 Part-­time employment as a percentage of total employment by sex and country, 2013 Total EU-­27 Austria Belgium Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Iceland Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Switzerland United Kingdom

Involuntary

Males

Females

Difference

Males

Females

8.8 8.8 8.7 2 5.3 8.4 2.5 14.8 5.5 8.8 6.7 9.5 5.3 4.1 10.8 13.5 7.4 5.7 6.4 5.1 6.7 26.2 14.2 4.5 8.1 8.4 3.3 6.5 7.7 12.8 13.3 11.4

32.3 45 42.5 3 7.3 15.6 10 35.3 12.4 19.4 30.4 45.4 12.6 9 31.6 35 31.8 9.4 10.2 35.9 26.5 77 41.1 10.4 13.9 9.3 6.2 12.6 25.2 37.7 60.3 41.5

–23.5 –36.2 –33.8 –1 –2 –7.2 –7.5 –20.5 –6.9 –10.6 –23.7 –35.9 –7.3 –4.9 –20.8 –21.5 –24.4 –3.7 –3.8 –30.8 –19.8 –50.8 –26.9 –5.9 –5.8 –0.9 –2.9 –6.1 –17.5 –24.9 –47 –30.1

40.2 16.9 13.7 65.8 28 62.5 8.6 15.2 19.5 28.7 45.4 24.6 70.7 47.1 16.4 61.7 76.7 40 32.7 9.8 25.9 13.5 16.1 30.4 43.1 68.2 34.2 8.8 70.1 31.6 10.3 38.4

26.3 10.6 8.5 58.6 19.2 51.9 19.5 19.7 18.1 24.7 38.0 13.9 66.7 41.9 18.1 35.1 58.6 41.0 32.7 10.8 11.9 8.6 19.7 31.2 53.3 45.5 31.2 11.8 60.8 29.0 6.8 14.8

Difference 13.9 6.3 5.2 7.2 8.8 10.6 –10.9 –4.5 1.4 4 7.4 10.7 4 5.2 –1.7 26.6 18.1 –1 0 –1 14 4.9 –3.6 –0.8 –10.2 22.7 3 –3 9.3 2.6 3.5 23.6

Source:  Eurostat, Labour Force Survey, April 2014.

source of cheap labour, in other countries the use of part-­timers represents an integration strategy used to retain valued workers (Kalleberg, 2000). For example, it has been reported that both British and Swedish part-­time employees face relative disadvantage when compared to female full-­ time workers. However, female part-­ time employees in Sweden hold positions of higher skill and have more autonomy compared to their equivalents in Britain. Therefore, it can be concluded that differences in the institutional

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A step forward in women’s occupational health  ­169 systems of Sweden and Britain do have a significant effect on the absolute skill level of part-­time work (Halldén et al., 2012). There is a horizontal division of the labour market, with the female working population densely concentrated in certain sectors of activity and in certain professions with relatively high levels of part-­time work, low pay, few career opportunities and limited access to further training (Kreimer, 2004). Moreover, many of them reproduce the traditional role of women at home. For example, according to data from the LFS, in the European Union (EU)-­27, in 2013 women accounted for 88.7 per cent of the sector of activities of households as employers of domestic personnel, 78.3 per cent of the human health and social work activities, and 71.8 per cent of education. Conversely, the proportion of men in the construction sector was 90.2 per cent; in electricity, gas, steam and air conditioning supply 76.2 per cent; and 70.6 per cent in manufacturing. In concentrating workers in predominantly one-­sex jobs, sex segregation converts individual-­level associations between workers’ sex and their job rewards into job-­level or occupational-­level associations between sex composition and employment rewards. In short, the larger men’s share in a line of work, the higher its rewards for workers of both sexes (Reskin and Bielby, 2005; Budig and England, 2001). Vertical segregation, that refers to the under-­representation of women in high-­status occupations, such as managers, and their over-­representation in low-­status occupations, such as clerical jobs, reinforces the effects of horizontal segregation (Kreimer, 2004). A highly counterintuitive cross-­national pattern of sex segregation exists whereby the more egalitarian countries, such as Nordic countries, have low levels of vertical segregation but high levels of horizontal segregation, which tend to produce high levels of overall segregation (Estevez-­Abe, 2005; Blackburn, 2006). This finding could be explained by the fact that the more an occupational career is confined to women, the greater the women’s chances of reaching high levels. In predominantly female occupations, such as nursing, the senior positions may be disproportionately held by men. However, the fewer the men available for promotion, the more women must fill the promoted positions (Blackburn, 2006). Conversely, countries with less support for working women – the Anglo-­American countries – have less sex-­segregated labour markets. Although some authors have partially explained the horizontal gender segregation of labour markets by gender differences in education, with men more likely to study technical subjects with a corresponding pattern of occupational selection (Blackburn, 2006), others have emphasized the powerful societal stereotypes that discourage women from studying scientific or technical studies from a very young age (Spelke, 2005; Halpern et al., 2007; Barres, 2006). The domain identification is used to describe achievement barriers still faced by women. The theory assumes that sustained school success requires identification with school and its subdomains; that societal pressures on women can frustrate this identification; and that in school domains where these groups are negatively stereotyped, those who have become domain-­identified face the further barrier of stereotype threat, the threat that others’ judgements or their own actions will negatively stereotype them in the domain. Research shows that this threat dramatically depresses the standardized test performance of women who are in the academic vanguard of their groups (Steele, 1997). Moreover, several studies relate vertical segregation with discrimination of women (Wenneràs and Wold, 1997; Charles, 2011).

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170  Handbook on gender and health

GENDER SEGREGATION IN THE DOMESTIC SPHERE While studies about occupational gender segregation, gender differences in wages and workplace authority have contributed much to our understanding of gender stratification, stratification processes within families have been studied less. These processes, which do not take place in the public sphere of the labour market, nevertheless constitute an important aspect of gender stratification. The division of domestic labour is one example of gender stratification within families, yet it has not been fully integrated into the larger framework of gender stratification. Steep increases in female educational attainment and labour force participation have not produced comparable changes with respect to the division of labour at home. Although formal family and marriage laws have become more gender-­egalitarian in most countries, women everywhere continue to do most of the core household and child care work (Geist, 2005; Iversen and Rosenbluth, 2006) (Figure 10.1). Previous studies about gender inequalities in the private sphere have been focused on the share of domestic work between men and women, neglecting the breadwinner role. In most countries, men continue as the main contributors to the household income, and although there are differences in the magnitude of these gender differences, they are present across European countries (Figure 10.2). As we will see, this gender division of roles in the private sphere contributes to explain work-­related gender inequalities in health. Nordic Southern Europe Eastern Europe

Women

Ireland/UK Continental

Nordic Southern Europe Eastern Europe

Men

Ireland/UK Continental 0%

20%

40%

60%

80%

Everyday – > 1 hours

Every 2nd day 0.001 0.041 0.759 0.002 0.001

Effort–reward imbalance model: High effort Low reward Effort–reward imbalance

30.0 48.0 51.0

27.0 44.0 49.0

28.0 45.0 50.0

0.171 0.042 0.322

Source:  Encuesta Araucaria (2011).

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212  Handbook on gender and health Table 12.3 Associations between psychological harassment and workplace psychosocial risks by gender Psychosocial risks

Job strain Isostrain Effort–reward imbalance High psychological demands Low decision latitude Low social support

Psychosocial violence (Odds ratio, n males = 1471; n females = 1426) Females

Males

3.05 (2.04–4.56) 4.01 (2.54–6.33) 3.6 (2.32–5.63) 4.91 (3.05–7.80) 1.61 (1.11–2.34) 5.73 (3.74–8.78)

3.3 (2.38–4.68) 5.5 (3.86–8.06) 2.85 (2.01–4.02) 2.42 (1.77–3.30) 2.34 (1.73–3.18) 5.28 (3.80–7.33)

Source:  Encuesta Araucaria (2011).

were three times more likely to report psychological harassment than those not exposed to job strain. However, that association had different explanations for men and women. A larger proportion of women than men reported high demands (p = 0.001) which, in turn, was related to a much greater likelihood of experiencing psychological harassment (4.01 times, versus 2.4 times for men). But while a higher percentage of women than men reported low decision latitude (the second dimension of the indicator), this dimension had little influence on their probability of experiencing psychological harassment, in contrast to what was observed in the case of men (Table 12.3). Moreover, workers exposed to isostrain were much more likely to experience psychological harassment than those who were not exposed to it, and this probability was five times greater among men and slightly lower in the case of women (OR = 4.01). It should be noted that in this indicator the social support dimension showed the strongest association with workplace violence, for both genders (Table 12.3). On the other hand, female workers who were exposed to an effort–reward imbalance were 3.5 times more likely to experience psychological harassment than those who were not exposed, while in the case of men the magnitude of the association is slightly lower (OR = 2.85) (Table 12.3). In relation to exposure to verbal or physical aggression and sexual harassment, no associations were found with psychosocial risks in the case of men. Among women, verbal or physical aggression and sexual harassment had a significant association only with the high psychological demands dimension (p = 0.007 and p = 0.08, respectively). Mental health, violence in the workplace and gender The analysis of the three mental health indicators showed a much higher prevalence of distress, symptoms of depression and consumption of psychotropic drugs among women than men. These results confirm the trends indicated by studies conducted in Chile and internationally (Ministerio de Salud, 2010; Ministerio de Salud et al., 2011; Vézina et al., 2011). In effect, 18 percent of the population surveyed presented psychological distress, and more women than men reported this symptomatology (24 and 15 percent, respectively). In addition, 9 percent presented symptoms of depression, and this figure was significantly higher among women (15 percent versus 5 percent of men). Finally, 15 percent

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Gendered work violence issues and mental health  ­213 of the workers surveyed said they had taken at least one type of medication for anxiety, depression or insomnia; the percentage of women who did so was twice that of men (20 percent versus 10 percent, respectively). In regard to the links between these indicators and exposure to some of the three forms of workplace violence studied, associations were found between the mental health indicators and psychological harassment and sexual harassment, and to a lesser extent between the indicators and verbal or physical aggression (Table 12.4). As can be seen in Table 12.4, the presence of psychological harassment showed a strong and significant association Table 12.4 Salaried victims of violence, by whether they consume psychotropic drugs, with or without distress, and with symptoms of depression by gender Proportion of workers victims of violence at work by distress (%) Females

Males

With distress

Without distress

p

With distress

Without distress

P

27.4

8.30

< 0.001

19.5

6.8

< 0.001

0.666

10.1

11.0

0.697

Psychological harassment n Females = 187 n Males = 131 Verbal or physical violence n F = 231 n M = 166 Sexual harassment n M = 36 n H = 17

14.8 4.75

15.8 1.66

0.001

3.85

0.69