Mary is a 35 year-old woman living in Rwanda. During the 1994 genocide, she was raped and her husband and oldest child were killed. Banished by her community for bearing the stigma of rape, Mary and her three remaining children were forced to relocate to a more remote community 10 kilometers from any water source. Mary soon contracted cholera from the untreated drinking water. With the country's rudimentary public health system in tatters after the genocide, Mary could not access medical treatment. The cholera proved fatal, leaving Mary's four-year-old son an orphan.
Three years ago, the area around Carmelita's village on the North Atlantic Coast of Nicaragua became the site of a logging project. A large tract of land that villagers relied on for hunting and fishing was taken over by the loggers. The medicinal plants that villagers had used to treat injury and illness were deep in the forest that now "belonged" to the timber company. Pollutants from the project contaminated the river, killing the fish and river plants that had been a mainstay of the community's diet. Within one year, Carmelita and her children began showing signs of malnutrition.
Cristina lives in Guatemala City. Working long hours in a dirty, high-stress maquila (sweatshop) and living in an overcrowded slum, she contracted tuberculosis. Because of hospital "user fees" and a rise in the cost of pharmaceuticals, Cristina did not have enough money to pay for medicine. She had no choice but to continue her work at the maquila, and her condition has steadily worsened.
We tend to think of health mainly as a function of biology, but as the above scenarios suggest, the strongest determinants of health are actually the social, political and economic forces in our lives. Health is not only the absence of disease or infirmity, but also a state of physical, mental and social well-being. How healthy we are depends enormously on our access to nutritious food, clean water and medical care, on the levels of violence and stress in our lives, on how much and under what conditions we work and on the opportunities we have for love, pleasure and fulfillment. In the US, the notion that health is mainly a measure of medical fitness and a commodity that can be purchased (whether over the counter, in the gym or at the doctor's office) creates confusion between health, broadly defined as our well-being, and medicine, or institutionalized treatment from professional practitioners.
Medical intervention can provide people with critical treatment. Our level of health, however, is not a simple function of the availability of medical services. Mary's poverty stemming from violence and gender inequality; Carmelita's malnutrition as a result of landlessness; and Cristina's deteriorating health as a result of sweatshop working conditions are all examples of social, political and economic forces at work. Each woman's state of health has less to do with her individual actions than with these larger causes. In fact, social and economic inequality, both between men and women and among different groups of women, is the biggest obstacle to good health for women around the world.
Because women experience inequality based on gender as well as forms of discrimination that men endure, women's health is often worse. Around the world, women die from overwhelmingly preventable causes because of the combined impact of being women, being targets of racism and being poor. Rates of maternal mortality (the number of women's deaths during pregnancy and childbirth per 100,000 women of reproductive age) are one of the best measures of the overall health of a society.1 Because most pregnancy-related deaths are preventable, maternal mortality figures also provide a sharp illustration of the matrix of social inequalities that interact to claim the lives of more than half a million women each year, or one woman every minute.2 Pregnant and childbearing women die because their basic nutrition is compromised, their reproductive rights are violated, and their access to medical care is denied as a result of gender inequality. For example, in societies where it is unacceptable for women to leave the house without their husbands' permission, pregnant women who need medical assistance face a risk of serious complications and death if their husbands are not home to grant them permission to seek medical care. Women also die because they have been subjected to colonization and racism. In Guatemala, for example, maternal mortality among Indigenous women is three times higher than among non-Indigenous women.3 And women die because public health budgets in the poorest countries have been slashed by US-driven economic policies: today, a full 99 percent of maternal fatalities occur in poor countries with inadequate healthcare systems.4
Undermining Women's Health
To grasp the connections between social inequalities and poor health, we need to understand how different forms of inequality based on gender, race and class interact to create conditions that threaten women's health.Gender Inequality
Inequality between men and women is a major threat to women's health. Nutrition is probably the single greatest determinant of good health. Yet, around the world, girls and women receive less food than men and boys when food is scarce. Women generally receive less protein-rich food than men even when they are pregnant or nursing. In most countries, cultural norms, religious teachings and government policies restrict women's access to contraception, abortion and information about reproductive health, robbing them of the right to decide whether and how often to have children. Data from Brazil, Egypt, India and Mexico shows that where women gain control of their fertility, births decrease substantially.5 Fewer unwanted pregnancies mean fewer unsafe abortions, a leading cause of maternal mortality in poor countries, where 95 percent of deaths from unsafe abortions occur.6 Early marriage for young women is another expression of gender inequality that endangers women's health. In many poor countries, a combination of cultural and economic factors lead girls to marry during adolescence and face significant risks associated with early childbearing: girls who begin having children before the age of 15 are four times more likely than women over the age of 20 to die from pregnancy-related causes.7
Violence committed against women by male family members and sexual partners is the leading cause of injury to women worldwide and a fundamental expression of gender inequality.8 Around the world, more women between the ages of 15 and 44 are killed or disabled by gender-based violence than by cancer, malaria and traffic accidents combined.9 In many families and communities, male violence is an accepted way for men to assert control over women and relieve stress. Domestic violence often escalates when men feel their traditional gender roles threatened as a result of rapidly shifting social dynamics or experience heightened anxiety because of economic crisis, migration, natural disasters, political upheaval or war. In addition to direct psychological and physical injuries, gender-based violence greatly undermines women's ability to make decisions concerning their health. For instance, a 2003 Human Rights Watch report in Uganda found that violence against women, particularly marital rape, contributes to the spread of HIV/AIDS in that country. Human Rights Watch recommended that the Ugandan government combat domestic violence as a way to slow the spread of HIV/AIDS after hearing from many Ugandan women that "fear of violent repercussions impeded their access to HIV/AIDS information, HIV testing, and HIV/AIDS treatment and counseling."10
Most acts of violence against girls and women, including psychological abuse, battery, dowry-related violence, marital rape and female genital mutilation, are perpetrated within the family. But women are also exposed to gender violence in the public sphere, including sexual harassment, rape, trafficking in women, forced prostitution and gender-based violence perpetrated by armed forces, including rape, forced pregnancy and sexual mutilation committed as acts of war. Today, the World Health Organization estimates that one in three women worldwide will experience physical and sexual violence in her lifetime.11 In fact, in the hour or so that it takes to read this chapter, at least 240 women in the United States alone will be battered by their partners and a comparable number of girls in Africa will undergo genital mutilation.12
Gender discrimination takes different forms depending on other aspects of women's identities. For example, poor women who live in communities where medical care is scarce often receive less treatment than men. In Latin America, user fees at privatized clinics and hospitals mean that millions of women can no longer afford treatment. Men are also affected by privatization, but women's lower status means they are less likely to have access to the little care available. Similarly, in sub-Saharan Africa, more women than men suffer from HIV/AIDS, but almost all hospital beds are filled by men.13 While a lack of medical treatment disproportionately harms women in communities with inadequate healthcare, wealthier women in the US are often subjected to over-medicating. Women are administered nearly two-thirds of all prescribed pharmaceutical drugs. Women are also inappropriately medicated. They are twice as likely as men to receive mood-altering drugs for problems like depression and anxiety, whose causes may be social. And women are subjected to high rates of unnecessary surgery, especially hysterectomy and Cesarean section. Finally, women's health, including that of wealthier women, is undermined by a medical establishment that treats men's bodies as the standard in medical research and testing. For poor and wealthy women alike, health is often undermined by some of the most common aspects of gender discrimination: women are often less valued by their families and communities than men; women often value themselves less than other family members; women are taught to sacrifice their own well-being for the sake of others; hatred of women's bodies and sexuality breeds shame that prevents women from seeking medical care; and the notion that women's pain and suffering are somehow "natural" is reinforced by religious doctrine and by a medical model that pathologizes women's healthy reproductive capacities as infirmity.Gender Discrimination and Institutionalized Religion
One of the most powerful forces to perpetuate women's subordination—a root cause of poor health—is institutionalized religion. By sanctioning patriarchal authority and encouraging reconciliation in cases of domestic violence, many religious doctrines expose women to rape and battery.
Because of its prominent role in policy-making around the world, the hierarchy of the Catholic Church has a particularly damaging impact on women's health. Violations of women's right to reproductive and sexual health stem directly from Church dogma, which denies women the right to make choices about their sexuality and fertility. When women are unable to control the number and spacing of their children, they are often prevented from exercising other basic human rights, such as the rights to employment, education and self-determination.
The impact of the Church's views extends even beyond its one billion members. The Holy See (the government of the Catholic Church) is the only religious entity that has non-member state permanent observer status at the United Nations. In contrast to all other religions, the Holy See has active participatory and special voting privileges at UN conferences and meetings. This status gives the Church leadership enormous leverage in shaping international human rights standards, international law and public policies that have a tremendous impact on people around the world, especially women.
The Holy See works hard to influence reproductive health policies: At the 1995 Beijing Conference on Women, the Church lobbied against advances made in women's control of their sexuality and fertility; in 1999, it blocked efforts to include emergency contraception in international policy guidelines; and later that year, the Holy See attacked the UN Foundation for Population Activities for distributing emergency contraception to Kosovar refugees who had been raped. The Holy See regularly makes alliances with governments such as the United States, Pakistan, Nicaragua and Sudan and that seek to deny women their sexual rights, and reproductive rights.
The hierarchy of the Catholic Church is a powerful political force throughout Latin America and the Caribbean. In the 1990's, the defeat and co-optation of Latin American liberation movements refortified the role of the Church in national politics. Throughout the region, Church leaders have worked to block and overturn progressive legislation on women's reproductive rights, prohibiting all abortions, even in circumstances of rape. In recent years, the number of Catholic hospitals in both Latin America and the US has grown as a result of privatization and hospital mergers. Consequently, many women are forced to seek treatment in facilities that refuse to provide critical reproductive health services. This trend is contributing to the 80,000 yearly deaths worldwide caused by unsafe, illegal abortions.
Even in many non-Catholic countries, the Church hierarchy has a stranglehold on national health policy because it supports a vast network of humanitarian relief programs on which poor governments depend. As Ms. Magazine has written, "the poorer the country, the greater the Vatican's influence."14 The Catholic Church funds more than 300,000 health facilities worldwide and has made clear that it would withdraw its support if those facilities were to offer condoms to men who are HIV positive or provide abortion services to their patients.
Each year, over half a million women die needlessly during pregnancy and childbirth, nearly six million people become HIV positive and an estimated one-third of all women are battered by male relatives or partners. High-quality, full-range women's health services combined with health education for women are a key to transforming this grim reality. This is one reason why thousands of women (including practicing Catholics) are working to change the status of the Holy See at the United Nations from a state actor to a non-governmental organization (the same status as other religions) through the global "See Change" Campaign, coordinated by Catholics for a Free Choice.15
When it comes to undermining women's reproductive rights, the United States is the Vatican's most powerful ally. In fact, women's health advocates from around the world have described US family planning policy under George W. Bush as a virtual "war against women." Planned Parenthood International has stated that, "Since his first day in office, George W. Bush has appeased his domestic hard-right political base by pursuing a steady campaign to eliminate reproductive freedom. He has revived retrograde anti-choice policies, installed religious political extremists in key administration posts and on the federal bench, and pushed ideology rather than scientific or medical evidence in domestic and international reproductive health policy."16 Many people interpret these measures as an expression of Bush's opposition to abortion. But a small sample of his actions points to a much broader policy of denying women their internationally protected right to exercise full and informed choices in their reproductive lives. The result is a threat to women's health, human rights and gender equality in the US and around the world. As always, those who come under attack first are poor women who rely on public healthcare initiatives that are partially funded by the US.Racism
For millions of people, racism is a major source of stress-related illness and violence and a serious obstacle to obtaining needed medical care. For example, in 2001, the director of the United States Agency for International Development stated publicly that AIDS drugs "wouldn't work" in Africa because Africans don't use clocks and "don't know what Western time is."17 Throughout much of Latin America, the ongoing destruction of Indigenous cultures has meant the loss of traditional healing and healthcare practices. Meanwhile, Indigenous women are effectively denied access to most public services, including medical care. In fact, the medical system is often a site of disrespect, hostility and even violence towards Indigenous women. Many professional health providers do not speak Indigenous languages. Indigenous women rarely participate in the design of public health programs, which, consequently, often fail to address their needs. Examination by male doctors is often culturally unacceptable, but may be the only available option. And in numerous Latin American countries (as well as the US), Indigenous women and women of African descent seeking professional health care have been forcibly sterilized.18
The history of racism has a palpable effect on the health of formerly enslaved and colonized peoples today. For example, the roots of Haiti's public health crisis can be traced directly to its history of slavery. In 1804, when Haitians finally won independence from France and ended slavery, nearly all of the European doctors who "tended" the slaves left the country. Indigenous health practices were annihilated along with the Arawak people and much African knowledge of health and healing was lost during slavery. Haiti was left with virtually no health system. Since independence, US economic blockade, invasion, occupation and devastating economic policies have further undermined Haitian efforts to develop a public health system. Today, racism continues to reinforce the assumption among many in the US that Haitians are incapable of self-government, including management of public health.
Inside the United States, people of color have historically suffered poorer health than whites and their health is worsening. Native Americans now die from diabetes at a rate 380 percent higher than whites. Black women are three times more likely than white women to die during pregnancy and four times more likely to die in childbirth. Maternal mortality for Latinas in the US is 23 percent higher than for non-Latinas.19 Life expectancy and infant mortality in some US communities of color are now worse than in some poor countries. For example, Detroit has a higher infant mortality rate than Jamaica.20 The biggest risk to babies is low birth weight, which is largely preventable, but requires precisely the kind of investment in education, reproductive health services and food assistance programs that have been eroded by neo-liberal policies like Clinton's 1996 "welfare reform" act and Bush's massive 2003 tax cut to the richest 1 percent of Americans. In fact, US statistics chart a clear correlation between worsening social inequality and poverty under Clinton and Bush and a steady rise in premature and low birth weight babies.21 But even within the same economic class, black babies die at higher rates than white babies—a testimony to the compounded and enduring effects of poverty and racism.
The interplay of racism, gender inequality and economic exploitation is clearly manifested in aspects of US international family planning policies, which have resulted in violations of women's reproductive rights and threats to women's health. In the 1930's and 1950's, the US utilized Puerto Rico's public health system to conduct a mass campaign of female sterilization. Women were told that a sterilization certificate would increase their chances for employment and migration to the United States, where they might escape the grinding poverty of the "welfare island." Puerto Rican women were also unknowingly used as guinea pigs by US pharmaceutical companies developing birth control pills. Through family planning clinics established by the US government, hundreds of thousands of Puerto Rican women were given birth control pills with hormone levels twenty times higher than what is now considered to be safe. Today, more than a third of women of child-bearing age in Puerto Rico have been sterilized and sterilization rates for Puerto Rican women living in the US are even higher—nearly 70% in Brooklyn, New York, for example.22
These days, concern about the status of women is sometimes invoked by government officials and development experts in family planning circles. However, the dominant approach to women's health remains instrumental, with women's bodies serving as sites for achieving policy objectives like regulating immigration and the growth of certain labor forces. During her first weeks in office, Clinton's Secretary of State Madeleine Albright explained that "family planning is an important component of United States' foreign policy."23 Albright emphasized the importance of "stabilizing population growth rates" in the global South and said that "family planning programs serve our broader interest by elevating the status of women... and reducing the flow of refugees."
Poverty and the Global Economy
Wealth once amassed through slavery and colonization is today generated by economic policies imposed by Northern (rich, industrialized) countries on former colonies. Today, poverty is the root cause of most people's poor health. It is the main reason that people go hungry, can't vaccinate their babies and lack clean water and sanitation. And poverty is a major contributor to serious public health problems like violence, mental illness, stress and substance abuse. Seventy percent of the world's poor are women, millions of whom suffer from preventable diseases like intestinal parasites, skin diseases, malaria, measles, diarrhea, ulcers, hypertension, malnutrition, typhoid and tuberculosis. Since health systems have been dismantled by neo-liberal policies, diseases once thought to be nearly eradicated, like polio and leprosy, have reappeared in poor communities.
Around the world, policies that have exacerbated poverty and inequality have also undermined public health. Debt servicing (interest payments on money owed to rich countries), for example, eats up a larger share of many national budgets than health care. Today, 10 million children under the age of five die annually, most from easily preventable illnesses.24 Ninety-seven percent of these deaths occur in heavily indebted poor countries. Since the 1980s, Structural Adjustment Programs (SAPs) have been imposed by the World Bank and International Monetary Fund on most of the world's poor countries, with devastating consequences for public health. In Africa, for example, maternal mortality has risen sharply since the advent of SAPs. One culprit was the introduction of user fees for health services, which made medical care unaffordable to many women. For instance, Zimbabwe's maternal mortality rate rose from 90 deaths per 100,000 live births to 168 per 100,000 in the three years after user fees were introduced in 1990. At a Dakar, Senegal meeting of women representing community-based organizations, public policy institutes and church groups from 15 African countries, participants identified threats to women's health that they associated with SAPs . These included a rise in family, ethnic and tribal conflict; street crime; prostitution; homelessness; alcoholism; drug addiction and violence against women; and a decline in girls' school attendance; increased workload and psychological stress for women; increased maternal and infant mortality; malnutrition; lack of access to medical treatment and an increase in toxic waste dumping in their communities.25
In the US, where privatization of health care was first initiated and is now most advanced, there has been a decline in the quality and quantity of health care available to poor communities and communities of color. This deprivation has a special impact on women, who use the medical system twice as often as men because they are usually responsible for the care of children and the elderly.
The frightening regression in health and health care contrasts sharply with encouraging media reports about increased life expectancy and breakthroughs in medical technology. While there have been important recent advances in medicine, the good news mainly benefits the world's elites. Countries where most poor people live now carry 90 percent of the disease burden, but have access to only 10 percent of the world's health resources.26One source of the disparity is the pharmaceutical industry, which has little profit motive for developing affordable treatments for diseases that primarily affect poor people, like malaria, tuberculosis and AIDS. In fact, just one percent of the nearly 1,400 new drugs approved between 1977 and 1999 were developed to treat tropical diseases that mainly affect poor people. Most drugs—over 80 percent—are manufactured to treat conditions that predominate in the global North.27 Nearly half of the industry's sales are lifestyle drugs such as the erectile dysfunction remedy, Viagra, which has generated 6.4 billion in profits since it was introduced in the United States in 1998.28
The World Bank Takes Over Health Care
A look at the World Bank's growing role in health care shows how macro-economic policies shape public health. During its first 30 years, the World Bank had no say in health policy. Its mandate, after all, is to ensure that countries repay their foreign debt. In this capacity the Bank often directs governments to cut expenses, including health spending, in order to shift money to debt servicing. Today, the Bank dwarfs even the World Health Organization (an independent agency of the UN) as global health policy maker. The World Bank is now the single biggest funder of health systems in many poor countries and actually designs the national health policy of many governments.
The bank's policy of reducing government spending by downscaling public health systems overwhelmingly harms poor people who cannot afford to pay for private doctors and hospitals. Few national governments have defended their poorer citizens by refusing to implement cutbacks at their expense. Even in the poorest countries government policy usually reflects the interests of national elites. Moreover, heavily indebted governments are extremely vulnerable to political pressure exerted by the World Bank because they are dependent on the Bank for new loans.
Worldwide, women work twice as many hours as men. Economic policies including privatization of health services, deregulation of industry and trade rules that prioritize corporate profits over human rights have forced millions of women into dangerous and unhealthy jobs in sweatshops, factory farms, exploitative domestic environments and the sex industry. The full-time task of caring for and maintaining their families and households adds to this tremendous strain. The health consequences of overwork, including severe physical and psychological stress, remind us that rest, pleasure and time for oneself, friends and family are not luxuries, but necessary elements of health that are denied to millions of women worldwide.
Health Care is a Human Right
Cuba, an impoverished country by most standards, has excellent health indicators, showing that an equitable distribution of resources is the single most important determinant of public health. Yet policies that produce inequality and poverty are usually ignored in public health outcomes. Instead, local and cultural factors are highlighted. For example, as Dr. Paul Farmer, long-time health advocate of the poor and co-founder of the organization Partners In Health, points out, the main lesson to be learned from Haiti's exploding HIV/AIDS rate in the early 1990s was that AIDS would ravage societies with high levels of poverty, instability and inequality.29 A decade later, the toll of AIDS in Haiti and sub-Saharan Africa testified to Dr. Farmer's grim prediction. But in both Haiti and Africa, much of the US medical establishment ignored socio-economic factors that fuel the spread of HIV/AIDS. Rather than focus on armed conflict, mass migration and international trade regulations that barred poor countries from purchasing AIDS drugs, many mainstream doctors and researchers studied "exotic" sexual and ritual practices in Haiti and southern Africa and "genetic" factors based on race.
Similarly, many large health agencies believe that "culturally sensitive education" is the best guarantee of halting HIV/AIDS transmission. While culture is always a facet of human behavior, economic necessity, not culture, is the biggest reason women enter into multiple sexual partnerships or barter sex for food and shelter. In fact, poverty and gender inequality are the primary risk factors for exposure to HIV/AIDS. For many women, the immediate need to guarantee survival for themselves and their children forces them to face longer-term dangers, including HIV/AIDS. Conventional wisdom about the spread of AIDS tells us that women are at risk because they do not use condoms. Yet without the resources to live independently of men, women lack the power to negotiate condom use (and relationships with men in general).
Since health is determined largely by social forces, improving health for the world's majority requires enhancing the political power of poor and marginalized people. It requires grappling with issues like land reform and income distribution as surely as offering vaccinations and vitamins. Most policy makers would rather avoid this conclusion and tend to focus more on medical and technological solutions than on changing the social and economic conditions that generate poor health. This skewed focus often creates the impression that bad health is mainly a matter of bad luck. And just as impoverished people are frequently blamed for their poverty, their poor health is commonly attributed to individual behavior or culture.
MADRE Programs and Health
Rather than blame people for their own poor health, we need to target conditions that undermine people's ability to make the best choices for their health. Having this degree of control over one's life is linked to exercising power in other realms, like land use, systems of production and the political and legal frameworks in which we live. Like other human rights, guaranteeing optimum health for women ultimately means maximizing women's opportunities and capacities to make decisions and play leadership roles in our families, communities, countries and in the international arena. Based on this understanding of the relationship between women's health and human rights, MADRE, an international women's human rights organization, designs women's health programs with three interlocking goals: to provide women with high-quality, respectful healthcare in their communities; to strengthen women's capacity to exercise the best choices for their overall well-being (for example, by creating women's literacy, human rights education and leadership development programs); and to press for policies at all levels of government that protect women's health.
As governments have slashed public healthcare programs—whether by their own initiative, as in the US and Britain, or under orders from the World Bank and IMF, as in most poor countries—these budget cuts have placed a heavy burden on non-governmental organizations like the community-based women's groups that MADRE supports. These groups are now expected to deliver the healthcare that governments no longer provide. Indeed, around the world, women's organizations are filling the role of government in creating and running community health clinics, domestic violence shelters, AIDS-education programs, nutrition classes and more. These efforts are a powerful expression of women's abilities, resourcefulness and sheer hard work. But even the best local organizations cannot fill the role of responsible government, nor should they have to.
For small organizations, providing healthcare services to their communities can be a monumental task. Moreover, in today's neo-liberal climate, even offering such services is not enough. Local activists also need to know how to mobilize at the municipal and national levels to hold their governments accountable to meeting people's basic needs. Here, women's health advocates face a big challenge, for governments themselves often generate major threats to women's health. Consider the issue of violence against women. Scholar/activist and MADRE supporter Angela Davis has pointed out the contradiction between seeking legal remedies to combat violence against women and appealing to state institutions which themselves perpetrate violence, particularly against poor women and men of color. Davis questions whether women who are from communities that have been targeted for state violence—such as Native Americans, immigrants, women of color, poor and homeless women—can rely on state institutions to prevent or redress gender-based violence. She asks, "can a state that is thoroughly infused with racism, male dominance, class-bias, and homophobia and that constructs itself in and through violence act to minimize violence in the lives of women?"30
Davis urges anti-violence activists to "develop an approach that relies on political mobilization rather than legal remedies or social service delivery. We need to fight for temporary and long-term solutions to violence and simultaneously think about and link global capitalism, global colonialism, racism, and patriarchy—all the forces that shape violence against women of color."31 Similarly, MADRE's community women's health programs encompass the need to advocate in the international arena to demand macro-economic policies that respect human rights, including the right to health care. To meet this need, MADRE provides trainings for women from our sister organizations in legal advocacy, human rights literacy, community organizing, media campaigning and more. These trainings equip women to address the interplay of local, national and global issues in order to effectively defend their right to health and healthcare.
MADRE's women's health programs have addressed a broad range of needs and conditions in more than 12 countries. For example, in the 1980s, MADRE organized mobile "suitcase" clinics for women and families who were in hiding from right-wing military forces in the mountains of El Salvador. In 1994, MADRE co-founded the first and only Haitian clinic dedicated to women's health and human rights, serving women who had been raped as part of the terror campaign against Haiti's pro-democracy movement. The clinic offered medical care, counseling, violence prevention education and legal advocacy for women in one of Port-au-Prince's poorest neighborhoods and linked local women's efforts to obtain justice for rape survivors to human rights advocacy in the international arena. MADRE has done similar work with survivors of war-time rape in the former Yugoslavia and Rwanda. In Nicaragua, MADRE has addressed the near-total lack of government health services in Indigenous communities on the North Atlantic Coast, providing emergency medicines and healthcare supplies in the wake of natural disaster; developing community education programs to combat malnutrition, family violence and drug abuse; providing local midwives with additional training and supplies; and co-founding the region's only women's health clinic, which combines traditional and Western medicine and provides full-spectrum reproductive healthcare. In Chiapas, Mexico and Palestine, MADRE has worked to provide trauma counseling to women and young people who have endured military violence and forced displacement and supported women's efforts to articulate and educate others about the dialectic between the rights of women within the community and the community's struggle for self-determination.
As Julia Scott of the National Black Women's Health Project and a member of the Steering Committee of MADRE's National Health Care Campaign said, "Good health requires the basic security of good nutrition and education, full employment, affordable housing and childcare, a clean environment, job safety and freedom from violence and war, racism and sexism, homophobia and ageism—as well as access to medical care."32 This inclusive definition reminds us that achieving optimal health for ourselves and our families depends in part on defending the health of an international movement that can make human rights a reality in our own lives and for women around the world.
By Yifat Susskind, Communications Director
1."Reduction of Maternal Mortality: A Joint WHO/UNFPA/UNICEF/World Bank Statement" World Health Organization, 1999, "http://www.who.int/reproductive- health/publications/reduction_of_maternal_mortality" (11 July 2003).
2.Human Development Report 2003, United Nations Development Programme (UNDP), 2003, http://www.undp.org/hdr2003/pdf/hdr03_overview.pdf (1 September 2003), 8.
3.Ministerio de Salud Pública y Asistencia Social (MSPAS), Línea Basal de Mortalidad Materna para el Año 2000, (Guatemala City: MSPAS, 2003), 16.
4.Womens' Health: Using Human Rights to Gain Reproductive Rights Panos Briefing No 32, Panos London Online, December 1998,"http://www.panos.org.uk/PDF/reports/WomensHealth.pdf" (17 July 2003), 10.
5. Barbara Crossette, Population Estimates Fall as Poor Women Assert Control, New York Times, 10 March 2002, sec. A.
6.Women's Health: Using Human Rights to Gain Reproductive Rights, 11.
7.Women's Health: Using Human Rights to Gain Reproductive Rights, 10.
7. Women's Health: Using Human Rights to Gain Reproductive Rights, 10.
8. Statistics Sisterhood Is Global Institute, November 25, 2001,"http://www.sigi.org/Resource/stats.htm" (4 August 2003.
9. Women's Health: Using Human Rights to Gain Reproductive Rights, 1.
10. "Uganda: Domestic Violence Worsens AIDS: Battered Women Face Greater Vulnerability to HIV Human Rights News," Human Rights Watch, 13 August 2003,"http://www.hrw.org/press/2003/08/uganda081303.htm" (13 August 2003).
12.Women's Health: Using Human Rights to Gain Reproductive Rights, I.
13. MADRE's Fact Finding Mission in Rwanda, Spring 2000.
14. Laura Flanders, Giving the Vatican the Boot, Ms., January 2000.
15. For more information, see Catholics for a Free Choice web site at"http://www.cath4choice.org".
16.Bush's War on Women: A Chronology, A Planned Parenthood Report on the Administration and Congress' Planned Parenthood Federation of America, 18 Jun 2003,"http://www.plannedparenthood.org/library/facts/030114_waronwomen.html" (20 June 2003).
17. Donald McNeil Jr., Africans Outdo Americans in Following AIDS Therapy, New York Times, September 3, sec. A.
18. Betsy Hartmann, Reproductive Rights and Wrongs: the Global Politics of Population Control. (Boston: South End Press, 1995), 177.
19. V.R.Randal, Racist Health Care: Reforming an Unjust Health Care System to Meet the Needs of African Americans, Health Matrix 3,(1993): 128.
20. Infant Mortality National Center for Health Statistics,"http://www.cdc.gov/nchs/fastats/infmort.htm" (17 July 2003); At a Glance: United Nation Children's Fund (UNICEF) "http://www.unicef.org/infobycountry/ jamaica_statistics.html"(17 July 2003).
21. Associated Press. June 26, 2003.
22. El Comite de Mujeres Puertorriquenas, In the Belly of the Beast: Puertorriquenas Challenging Colonialism, in Sing, Whisper, Shout, Pray: Feminist Visions for a Just World, eds. M. Jacqui Alexander et al., (EgdeWork Books, 2003), 128.
23. Katharine Q. Seelye, "Family Planning and Foreign Policy Are Linked, Albright Tells House Panel," New York Times, 12 February 1997, sec. A.
24. Sarah Boseley, Six Out of 10 Child deaths are preventable, The Guardian, 27 June 2003, 17.
25. Women Standing Up to Adjustment in Africa: A Report of the African Women's Economic Policy Network, AWEPON and The Development Gap, (July 1996)"http://www.developmentgap.org/awecov.html" (11 July 2002).
26. Gro Harlem Brundtland, Press Release WHO/93, World Health Organization, 8 December 1998, "http://www.who.int/inf-pr-1998/en/pr98-93.html" (22 July 2003).
27. GSonia Shah, An Unprofitable Disease, The Progressive, September 2002, 20.
28. Global Viagra Boosts Pfizer, IMS Health, "http://www.ims-global.com/insight/news_story/news_story_991007a.htm"(18 September 2003).
29. Paul Farmer, The Uses Of Haiti, (Monroe: Common Courage Press, 1994), 55.
30. Angela Davis, The Color of Violence Against Women, in Sing, Whisper, Shout, Pray: Feminist Visions for a Just World, eds. M. Jacqui Alexander et al., (EgdeWork Books, 2003), 30.
31. Davis, 30.
32. Vital Signs. Atlanta, GA. 1988. Newsletter of the National Black Women's Health Project