Sophie Harman, Sick of It: the Global Fight for Women's Health, Virago, 2024. Hbk £22 (or less), pbk July 2025, also available as E-book and audio book.
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In Sick Of It, Sophie Harman addresses the fact that despite the enormous global resources devoted to women's health, women still far too often die when they should not have to. Maternal mortality (death due to complications from pregnancy or childbirth) is by no means the only cause. But along with HIV/Aids it is the leading cause of premature death for women of childbearing age, and the principal focus of activity of the charities and UN-related international organisations working in global health, of which Harman has expert knowledge. She provides much of the relevant background, but for the full picture I turn first to four excellent multi-author articles on the theme of maternal health in the perinatal period and beyond, recently published under the auspices of The Lancet, with a preface and a series of comments, all free to download (www.thelancet.com/series/maternal-perinatal-health). Global maternal mortality stood at 339 per 100,000 live births in 2000 (pretty much as it was in the UK at the end of the nineteenth century), falling to 223 per 100,000 by 2020. This average annual rate of reduction of just over 2 per cent over twenty years is less than a third of the 6.4 per cent annual rate needed to achieve the Sustainable Development Goal (adopted in 2015 as part of a reworking of the 2000 Millennium Development Goals) of 70 maternal deaths per 100,000 live births by 2030; and, worse, it conceals the fact that progress has stalled over the last decade or so, and gone into reverse in some parts of the world. You might not guess which: 'since 2016 the MMR [Maternal Mortality Rate] has decreased in only two regions: central and south Asia, and Australia and New Zealand. Sub-Saharan Africa, Oceania (excluding Australia and New Zealand), east and southeast Asia, and north Africa all experienced a stagnation in the MMR. During this time period, the MMR increased in Europe, North America, Latin America, and the Caribbean’ (Souza et al 2024: e306). As a general rule, the poorer the country, the higher the mortality rate. Rwanda, discussed by Harman, is a conspicuous exception, as is Cuba, which she does not discuss. It has been for decades, and still is, despite its travails (Bohren et al 2024: 3-5). The other conspicuous exception is the United States, where rates are shamefully high, particularly among Black women. Souza et al identify the underlying social and economic circumstances and the quality of health systems as the most important determinants of outcomes. In particular, social aspects aside,
‘actions taken by the health system, at the health service level, represent a final opportunity to save the lives and improve the health and wellbeing of women who have birth-related complications. Expanding the health sector ecosystem and care networks to mitigate the detrimental effects of distal and proximal determinants will substantively improve maternal health. Expanding demand for and increasing access to high-quality reproductive health services and commodities (eg, modern contraception, safe abortion, and antenatal, intrapartum, and postpartum care) are needed for primary prevention, early identification, and adequate management of pregnancy complications. Achieving universal health coverage and strengthening the health system to provide quality care is essential to reduce maternal mortality and promote maternal health and wellbeing’ (e314, emphasis mine).
Harman is right, then, that hundreds of thousands of women (and infants) die every year when they should not have to, and right too to focus, as she does, on 'the last mile'. In the area of maternal mortality alone the remedies are well known, and in some cases inexpensive. Sheikh et al (2024: 2) review vulnerabilities and reparative strategies, and report, not surprisingly, that the impact of vulnerability during pregnancy and childbirth is particularly relevant to women in low-income and middle-income countries (LMICs), where the burden of maternal and perinatal mortality and morbidity is disproportionately high. They insist at the same time that specific vulnerabilities must be precisely identified if effectively targeted remedies are to be found. Their analysis broadens out to focus on the life course (ibid: 2-9), and brings home the huge interlinked challenges facing countries and health systems where resources are scarce, starting with the need for early identification of pregnancy, access to antenatal care, and skilled attendance at birth, and extending to low educational and economic status, child marriage, partner violence, and refugee status or residence in fragile or conflict-affected states. Among the shocking things they note, two stand out. ‘Maternal death rates were 100-fold higher in women undergoing a caesarean section, a potentially life-saving procedure, in LMICs than in high-income countries’; and ‘When taken as recommended, antenatal iron supplementation can prevent 20% of maternal deaths and halve neonatal mortality. Calcium supplementation in calcium-deficient populations reduces the risk of pre-eclampsia … and reduces severe morbidity and mortality by 20%’ (ibid: 9).
Complementing this, the third article looks at longer-term morbidity associated with giving birth - meaning consequences persisting or occurring more than six weeks after giving birth, this being a WHO (World Health Organisation) definition of the postpartum period (which, as the authors say, (Vogel et al 2024: e326) 'is not fit for purpose'): 'Available data show the most prevalent conditions are dyspareunia, or genital pain during or after sexual intercourse (35%), low back pain (32%), urinary incontinence (8–31%), anxiety (9–24%), anal incontinence (19%), depression (11–17%), tokophobia, or fear of giving birth (6–15%), perineal pain (11%), and secondary infertility (11%)' (ibid: e318). Here the most striking finding is the general dearth of data, with virtually no high-quality information from LMICs at all (ibid: e320-24). Consequently, 'the burden of medium-term and long-term conditions in LMICs remains largely unknown' (ibid e326). In light of all this, the final paper in the series looks at intersectional gendered power relations that drive differences in antenatal care in eight Caribbean and Latin American countries. 'To meet the ambitious objectives articulated in the Sustainable Development Goals and codified within the right to health,' the authors say, 'a broader vision that embraces the central role of power relations in maternal health is urgently needed' (Bohren et al 2024: 9). Drawing on the Respectful Maternity Care Charter (https://whiteribbonalliance.org/wp-content/uploads/2022/05/WRA_RMC_Charter_FINAL.pdf), they advocate community-based mechanisms to hold health workers and facilities accountable when mistreatment and discrimination occur, and quality improvement regimes that incorporate people's experience of care, along with complementary research into health inequities and social justice (ibid). Communities are the first port of call, then, and researchers the second. They then turn briefly to 're-imagining the global maternal health community', noting that policy 'operates at institutional, subnational, national, regional, and global levels, and all are useful levers to engender change' (ibid: 10). Professional associations, accrediting bodies, licensing organisations and Ministries of Health are identified, before concluding:
'At the global level, human rights approaches for health provide one avenue for engaging with intersectionality. The United Nations Special Rapporteur on the right to health has framed her mandate through the lens of intersectionality, illustrating how legacies of colonialism and other oppressive systems produce adverse outcomes, including in maternal health. Intersectionality also allows
for an understanding of overlapping State obligations for members of multiply marginalised populations. For example, States may have legal obligations to rectify inequities due to gender and disability under both the Convention on the Elimination of Discrimination against Women and the Convention on the Rights of Persons with Disabilities, underscoring the imperative to ensure
there is accessible quality maternity care available for women and birthing people with disabilities' (ibid).
Harman is well aware of all of this, and touches on much of it at various points in the book, but is concerned for the most part with the role of international organisations and charities, and their interaction with states and vulnerable people. As a consequence, she covers a rather narrower set of themes, centred on the suggestion that women still far too often die when they don't have to 'not because of a lack of attention, science or evidence on what works for women's health, but because of the exploitation of women's health as a means of attaining and sustaining power in the world' (5-6) - a 'sick politics' of using and abusing women's health for political ends. This argument is presented in three parts. The first, 'Saving Mothers', 'looks at how women's health - specifically maternal healthcare - is used as a tool to gain and sustain power in the world'; the second, 'Exploiting Women', looks at 'the way women are exploited within health and foreign aid sectors, often as collateral damage in the wider delivery of healthcare'; and the third, 'SOS! (Same Old Solutions)', looks at how solutions focused on leadership, gender experts, and better data 'can fail in practice, and what can be done about them' (9). She then shifts her focus in the conclusion, 'The Driver and the Green Wave': development agencies, the international politics of aid, and the issues of leadership, gender experts and data drop away, and the emphasis turns to the role of movements at national or sub-national level aimed at protecting women's rights over their bodies, and specifically the right to abortion. The book concludes with a brief epilogue, addressed initially to students, then towards people who work in development- or gender-related organizations: in the light of the issues raised, what can you do next? You will learn a lot from the book about the global politics of women's health, and particularly about the ways - some good, some bad - in which global institutions and charities involved with it operate.
It is important to know at the outset that at some point in the process of writing the book, Harman consigned an 'academic' draft to a drawer and decided on a 'more accessible' approach (acquiring an agent and an editor in the process). The book accordingly makes very little use of academic monographs and specialist journals - and reasonably so, as they are not available to the majority of those to whom the book is aimed. It is still informed, of course, by her knowledge of such sources, and very extensive fieldwork experience, participation in a wide range of global health and other organisations, and systematic investigation of their structure, funding, policy, strategies and policy advice; and it draws directly or indirectly on over 360 interviews. However, just as academic publishing has conventions that authors need to follow, so does work aimed as this book is at a different and wider audience. There is no point in half measures, and Harman embraces the form wholeheartedly. Whether off her own bat, or as a result of guidance, she is bang on message with the key points of successful contemporary communication: employ 'popular' rather than 'academic' language ('all the rage'; 'mad for it', 'a bit of a cop out', 'pet peeve', and - my favourite - 'Gosh, no' (5), for example); use the first person singular; draw on your own experience, vividly described; establish your expertise at the outset ('as a professor teaching global health politics at a London university' (1), 'fifteen years researching global health politics ... As a professor of international politics, I had conducted research all over the world, ...'(2); and present issues that can appear large and rather abstract through concrete examples - in this case, short profiles of specific individuals involved. I don't have any problem with most of this: readers need to know something about the writer, and it is nigh on impossible, as you will know if you have tried, to get anyone to read a whole book (article? chapter?) as part of a programme of study these days. But the last point - the use of individual vignettes to get the argument across - is different. It is standard fare at the World Bank, who pioneered it in the World Development Reports, and central to the communication strategies of all leading development organisations, and Harman condemns them roundly for it. So, she reports that at a morning session of the UN's 2019 population conference in Nairobi, the CEO of a major international charity gave her seat on the platform to 'Sylvie', a young woman from South Sudan, who proceeded to deliver what Harman describes as a 'three-part narrative' of trauma: the trauma itself, its impact, and how she turned her life around with the help of the international charity. The audience 'lapped it up', but Harman herself 'zoned out' and could not recall the details later. 'After Sylvie had told her story,' Harman reports, 'she was silent. No one asked her a question, she did not respond to any general questions in the Q&A, she did not go off script, and I had no idea what would happen to her after she finished. Like the kid dancing on stage with the poster at a concert, her participation had been rehearsed, she had her moment in the spotlight, and then it went back to the more powerful woman being the centre of attention' (88-9). This leads into one of the most prominent arguments in the book:
'What happened with Sylvie and the panel is a new version of an old tactic: the selling of women's trauma as a means of eliciting an emotional reaction in the audience so they act on the wider issue. ... The selling of trauma stories is prevalent in fundraising in the aid and health sector because such individual stories are seen to resonate and connect with people. If you have an issue you care about, say cervical cancer, it is not enough to say that cervical cancer kills 342,000 people a year, and is the fourth most common cancer among women. ... What you need is a story to tell. One with the right amount of trauma and redemption' (90-91).
All well and good. But hang on a minute. Go back a few pages and you find that Chapter Four opens with a vignette of 'Amina', a Palestinian woman from Ramallah who gave birth at a checkpoint outside East Jerusalem (taken from a story published in 2005). That is all we learn about her. Like Sylvie, she is reduced to a one-dimensional trauma story, but unlike her, she doesn't experience redemption, or get to speak for herself at all. She is not aware that she is heading up this chapter, or that she will likely become a trope in innumerable student essays and presentations in the future. If Sylvie's case is one of exploitation, isn't this one too? And there is more. We learn that 'the reproductive choices of women like Amina were controlled by Israeli permits, checkpoints, border crossings and ever-shifting rules and requirements', as in any settler colonial regime. True. And it is a fair bet that most readers will readily assent to the idea that the government of Israel is the bad guy here. So it is. But what about the limits placed on the reproductive choices of women like Amina by widespread pressure from husbands and wider family to have large numbers of children, especially boys? Or the fact that abortion (widely and easily available in Israel, including to Palestinian women) is illegal except in extreme circumstances in Gaza and the West Bank, and so available only illegally and at risk to the woman? Or that contraception is frowned upon socially in the case of married women with no or few children? Does Amina have children already? Was she under pressure to produce (another?) son? Would she have preferred not to be pregnant in the first place, or to terminate the pregnancy once she conceived? We will never know. She has become 'woman-who-delivered-baby-at-Israeli-checkpoint'. And there are many such examples throughout the book.
So the method Harman adopts involves an element of contradiction, which readers will just have to live with. The book is best seen as a series of set pieces, all informed by rage which is entirely justified, and they add up to a powerful indictment of the politics of global women's health. The majority of them relate to the world of international aid related to women's health:
#1 Rwanda uses its truly remarkable record on women's health, complemented by gender parity (in fact a clear female majority) in parliament, as a form of 'soft power': it has become the darling and favoured partner of international donors. Harman comments: 'Using women's health as a tool of soft power is not necessarily a bad thing: it would be great if all the countries in the world gained their standing, recognition and good diplomacy from helping women. But there is a sinister side to this. Rwanda uses its standing on women's health to 'healthwash' the unseemly, more murderous part of Rwandan politics' (21). International donors have decided to live with this, and Harman does not say they are wrong to do so.
#2 International aid in the 1990s was highly selective in its focus on 'saving mothers' - and babies - to the exclusion of other issues, such as the punitive impact on women of structural adjustment and the burden of reduced support and extra work it imposed. Along came the MDGs, but with an embedded compromise: 'in the new MDG era ... the focus would be on maternal health, not sexual and reproductive health. In other words, they took out the part of women's health the majority of governments in the world seek to restrict: abortion and contraception' (36). And when massive financing was directed towards HIV/AIDS, especially with US President George W. Bush's $100 billion President's Emergency Plan for AIDS Relief (PEPFAR) in 2003, it went along with the promotion of family values, abstinence, and monogamy, and left 'undeserving' drug users and sex workers out. Beyond this, the focus broadened to cash transfers paid directly to mothers, conditional on children turning up to school and to clinics for health checks and vaccinations. Such policies reflected gender stereotyping and added to women's already extensive responsibilities but, as Harman acknowledges, they worked (39).
#3 The 2015 MDGs included a target (3.7) on sexual and reproductive health: to ensure universal access by 2030 to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies, but access to safe abortion remained strictly off limits. And in sharp contrast to action on AIDS, all Republican Presidents from Reagan onwards uphold (and all Democratic Presidents overturn) the 'Mexico City Policy' (that being the site of the 1984 UN Conference on Population and Development), or global gag rule, which stipulates that no organisation abroad in receipt of US funds for family planning and reproductive health can discuss or conduct abortions. Trump took it further in 2017, extending it massively to UN agencies, and halting US funding for the UN Population Fund into the bargain (49-52), thereby reducing materially resources available for the full range of policies addressing sexual and reproductive health; Biden reversed it. What will happen next remains to be seen. The reduced availability of safe abortion does not reduce the number of abortions, it simply increases the number of unsafe ones. So with one hand the US under Republican presidents in particular and the international donor community generally act to reduce maternal mortality, with the other they place a leading cause off limits. Harman's extended discussion of the causes and consequences (53-68) is valuable.
#4 Amina's story (above) introduces a discussion on the politics of maternal health in zones of conflict in Gaza, the West Bank, Syria and Ukraine, cases 'united by an effort to control, curtail or destroy women's health services by one side of a dispute in order to defeat the other' (71). One telling statistic among many others is that Israeli settlers living in the West Bank in 2020 maternal mortality was nine times lower than for Palestinian women living there (75); and the deliberate targeting of hospitals that Harman records in Ukraine and in Syria has repeatedly occurred in Gaza too since the Hamas military operation of 7 October 2023.
#5 Sylvie's appearance at the UN (above) introduces the theme of 'the selling of women's trauma as a means of eliciting an emotional response in the audience so they act on a wider issue' (89). Turning to fundraising leaflets and campaigns, Harman comments: 'Look at those pictures. Chances are they are a woman, girl or boy, most likely with black or brown skin. They are rarely a man, and never a white man. Perhaps with good reason: these images represent the recipients of aid money. But ask yourself what they represent about the person, the country they live in, the charity, and the setting or context. What is problematic about these images is how the women in them are often defined by their trauma - whether they are still in need of help or have already been empowered - and the context in which these pictures are taken. The unsettling part is not just the use of such stories, but the fact that women and girls are approached for their stories when they seek out healthcare; and that it is the very organisations who are supposed to help vulnerable women and girls access health who are doing the exploitation (89-90, emphasis mine). Harman profiles the case of Médecins Sans Frontières (MSF), recounting that a photograph taken for purposes of publicity of a teenage victim of major sexual assault became available as a commercial stock image, on sale for £375 (93), along with thousands like it, and reporting a campaign launched in May 2022 to persuade MSF to halt the use of such images and their commercialisation (by photographers and agencies, as she notes, as they, not MSF, hold copyright). To judge by their website MSF may have changed its practice somewhat.
#6 In 2019, during an Ebola outbreak in the Democratic Republic of Congo (DRC) evidence emerged of the sexual harassment, abuse and exploitation of women and girls caught up in it by WHO health workers sent to help them. When an independent investigation was launched, more than fifty victims of abuse came forward, including women employed locally by the WHO itself (104-6). This was far from an isolated case: multiple cases were reported in the 1990s; and in February 2018 the Times reported systematic abuse by Oxfam staff in Haiti from 2011 onwards; similar abuses in the Horn of Africa subsequently came to light. The WHO was particularly slow to take action, and its director-general never took responsibility.
#7 All major global health initiatives depend on 'last mile' community health workers, 'mostly women and rarely paid properly' (154), and the global response to HIV/AIDS in the early years of this century is offered as a case in point. The efforts of international agencies and charities alike depend heavily on poorly paid or unpaid volunteers, caring for the sick and monitoring and reporting the incidence and spread of disease. The WHO puts the number at over 34 million, but the number is much higher than such formal estimates suggest.
#8 Three frequently canvassed solutions to the dismal record on global women's health - appointing women to leadership roles, employing 'gender experts', and developing better data - have yielded disappointing results. There are a small number of women in leading roles in global women's health (notably, the philanthropist, Melinda French Gates), and women 'hold 40 per cent of board seats of the most influential public and private health organisations in the world'. But 58 per cent of these have never had a female CEO, and 51 per cent have never had a female chair of the board (171). For the very top jobs, better-qualified women are frequently overlooked, losing out to more politically connected men: 'The trick that all working women come to realise at some point in their professional lives is you can work as hard as you can, do all the networking and be more qualified for the job, but you will never be seen as the most qualified candidate' (184). Gender experts are too often under-resourced, assigned trivial administrative tasks, used as window-dressing, ignored on major issues, and kept at arms length by tactics such as filibustering, which Harman illustrates with the 'Gender Filibuster Bingo Card' (201). As regards data, it can be transformative, and gender-relevant data is now collected much more widely than in the past. But its availability is still limited by government capacity, prejudice and discrimination, narrow and incorrect assumptions, and the sheer difficulty of getting down to local and community levels. There is a darker side, too - personal app-related data can be harvested and sold by Facebook, for example, handed over to the police, and used - as illustrated here - in successful prosecutions for illegal abortion (222-3).
At this point Harman turns her attention away from international agencies and charities, to focus in a brief conclusion on rights to safe and legal abortion - under threat in the United States, and recently won in Argentina. In each case, the focus is on grassroots action - the volunteer who drives strangers three or more times a week from Mississippi to Illinois to keep access to legal and safe abortion open, and the campaigners who won a change of law in Argentina in December 2020. Harman concludes this chapter, as she does the previous one, with a simple message: listen to women, and believe them.
This sets up the epilogue, which works well both as a conclusion, as it covers the main themes of the book, and as a graduated set of practical recommendations starting from the point that feeling hopeless gets us nowhere, avoiding guilt-tripping ('do absolutely nothing if you don't want to', 249), insisting again on the imperative need to believe women 'when they tell you they are sick, need money, have an idea, are being exploited or are injured pain' (255), and leading up to what is effectively a checklist code of good practice for professionals in the health aid industry.
So what do I make of the book overall? I have one grumble, and one caveat. The grumble relates to the couple of chapters slipped in midway through (7 and 8, 120-50) which address the violence to which health workers are subject, and the issue of burnout, both predominantly with reference to the UK. They don't fit well with the rest of book, and their placing seems arbitrary. Worse, this is the only point where Harman's exclusive focus on women appears to be seriously misleading. She moves from the fact that 70 per cent of front-line health workers are women to assert that: 'To take this issue seriously, violence against health workers needs to be seen for what it is: gender-based violence' (133). I think that this is a distortion. For example, a YouGov survey from 2022 reports that men are more likely to say they have experienced violence from patients than women are; 'Male and female NHS patient-facing healthcare workers report differing experiences of violence and aggression from patients. While a third (36%) of male healthcare workers report experiencing violence from a patient at least once a year, this figure falls to 28% of women. Similarly, a fifth (20%) of men say they’ve experienced violence from a patient’s family member, compared to 14% of women. ... However, when it comes to aggressive behaviour, the numbers are more even. Around the same proportion of male and female NHS patient-facing NHS workers say they have experienced aggressive behaviour from a patient at least once a year, 69% and 66% respectively. The figures are also similar for aggressive behaviour from a patient’s family member – 62% of men and 64% of women say they experience this at least once a year' (https://yougov.co.uk/health/articles/40710-three-10-healthcare-workers-say-they-experience-vi). And Harman reports the case of a health worker assaulted in Manchester in gender-neutral language, without disclosing that the victim was a man in his fifties (127, and see https://www.independent.co.uk/news/uk/crime/nhs-worker-assault-hospital-jail-salford-royal-infirmary-manchester-a9487526.html, 28 April 2020).
The caveat is this: the focus on institutions and charities concerned with global health inevitably gives only a partial picture of the dynamics of global development as they relate to women, or to orientations towards women on the part of the full set of global institutions. Harman does not say that the institutions and charities she discusses bear the primary responsibility for the parlous state of women's health in large parts of the world. As her text repeatedly reflects, it is primarily a consequence of the huge disparities of wealth and income across and within countries, along with social patterns which vary widely, but still predominantly subject girls and women to the authority of men. Realistically, they cannot substitute for the universal health coverage and strong indigenous health systems that Souza and his fellow authors identify as essential, let alone transform the societies in which they operate. This confronts them with recurrent dilemmas that she frequently addresses. But one particular set of issues is missing in her account. Taken as a whole, action on women's health on the part of international organisations goes way beyond a concern with maternal mortality and HIV/AIDS, and this is because the leading global agencies - the World Bank and the IMF - do not focus exclusively on women as mothers. Quite the contrary. The primary driving force behind their genuine concern with women's health (and education) is their desire to see more women productively employed in the global labour force: young women are potential workers before they are potential mothers. This is a caveat, rather than a criticism, because it lies outside Harman's chosen topic. And it is worth noting, when we are urged, fairly enough in context, to listen to women, that international organisations with an economic remit are happy hunting grounds for neoliberal feminists, and that the Managing Director of the IMF and her first deputy are both women; the President of the European Central Bank is a woman; the President of the ultra-neoliberal European Commission and more than half the Commissioners are women; the right-leaning ex-Bank of England British Chancellor of the Exchequer is a woman, as are half her ministerial team, and a majority of her civil service management team, and so on.
References
Bohren, Meghan A. et al. 2024. Towards a better tomorrow: addressing intersectional gender power relations to eradicate inequities in maternal health, eClinicalMedicine, 67, January.
Souza, João Paulo et al. 2024. A global analysis of the determinants of maternal health and transitions in maternal mortality, Lancet Global Health, 12, 2, 306-316.
Sheikh, Jameela, et al. 2024. Vulnerabilities and reparative strategies during pregnancy, childbirth, and the postpartum period: moving from rhetoric to action. eClinicalMedicine, 67, January.
Vogel, Joshua et al. 2024. Neglected medium-term and long-term consequences of labour and childbirth: a systematic analysis of the burden, recommended practices, and a way forward, Lancet Global Health, 12, 2, 317-330.
‘actions taken by the health system, at the health service level, represent a final opportunity to save the lives and improve the health and wellbeing of women who have birth-related complications. Expanding the health sector ecosystem and care networks to mitigate the detrimental effects of distal and proximal determinants will substantively improve maternal health. Expanding demand for and increasing access to high-quality reproductive health services and commodities (eg, modern contraception, safe abortion, and antenatal, intrapartum, and postpartum care) are needed for primary prevention, early identification, and adequate management of pregnancy complications. Achieving universal health coverage and strengthening the health system to provide quality care is essential to reduce maternal mortality and promote maternal health and wellbeing’ (e314, emphasis mine).
Harman is right, then, that hundreds of thousands of women (and infants) die every year when they should not have to, and right too to focus, as she does, on 'the last mile'. In the area of maternal mortality alone the remedies are well known, and in some cases inexpensive. Sheikh et al (2024: 2) review vulnerabilities and reparative strategies, and report, not surprisingly, that the impact of vulnerability during pregnancy and childbirth is particularly relevant to women in low-income and middle-income countries (LMICs), where the burden of maternal and perinatal mortality and morbidity is disproportionately high. They insist at the same time that specific vulnerabilities must be precisely identified if effectively targeted remedies are to be found. Their analysis broadens out to focus on the life course (ibid: 2-9), and brings home the huge interlinked challenges facing countries and health systems where resources are scarce, starting with the need for early identification of pregnancy, access to antenatal care, and skilled attendance at birth, and extending to low educational and economic status, child marriage, partner violence, and refugee status or residence in fragile or conflict-affected states. Among the shocking things they note, two stand out. ‘Maternal death rates were 100-fold higher in women undergoing a caesarean section, a potentially life-saving procedure, in LMICs than in high-income countries’; and ‘When taken as recommended, antenatal iron supplementation can prevent 20% of maternal deaths and halve neonatal mortality. Calcium supplementation in calcium-deficient populations reduces the risk of pre-eclampsia … and reduces severe morbidity and mortality by 20%’ (ibid: 9).
Complementing this, the third article looks at longer-term morbidity associated with giving birth - meaning consequences persisting or occurring more than six weeks after giving birth, this being a WHO (World Health Organisation) definition of the postpartum period (which, as the authors say, (Vogel et al 2024: e326) 'is not fit for purpose'): 'Available data show the most prevalent conditions are dyspareunia, or genital pain during or after sexual intercourse (35%), low back pain (32%), urinary incontinence (8–31%), anxiety (9–24%), anal incontinence (19%), depression (11–17%), tokophobia, or fear of giving birth (6–15%), perineal pain (11%), and secondary infertility (11%)' (ibid: e318). Here the most striking finding is the general dearth of data, with virtually no high-quality information from LMICs at all (ibid: e320-24). Consequently, 'the burden of medium-term and long-term conditions in LMICs remains largely unknown' (ibid e326). In light of all this, the final paper in the series looks at intersectional gendered power relations that drive differences in antenatal care in eight Caribbean and Latin American countries. 'To meet the ambitious objectives articulated in the Sustainable Development Goals and codified within the right to health,' the authors say, 'a broader vision that embraces the central role of power relations in maternal health is urgently needed' (Bohren et al 2024: 9). Drawing on the Respectful Maternity Care Charter (https://whiteribbonalliance.org/wp-content/uploads/2022/05/WRA_RMC_Charter_FINAL.pdf), they advocate community-based mechanisms to hold health workers and facilities accountable when mistreatment and discrimination occur, and quality improvement regimes that incorporate people's experience of care, along with complementary research into health inequities and social justice (ibid). Communities are the first port of call, then, and researchers the second. They then turn briefly to 're-imagining the global maternal health community', noting that policy 'operates at institutional, subnational, national, regional, and global levels, and all are useful levers to engender change' (ibid: 10). Professional associations, accrediting bodies, licensing organisations and Ministries of Health are identified, before concluding:
'At the global level, human rights approaches for health provide one avenue for engaging with intersectionality. The United Nations Special Rapporteur on the right to health has framed her mandate through the lens of intersectionality, illustrating how legacies of colonialism and other oppressive systems produce adverse outcomes, including in maternal health. Intersectionality also allows
for an understanding of overlapping State obligations for members of multiply marginalised populations. For example, States may have legal obligations to rectify inequities due to gender and disability under both the Convention on the Elimination of Discrimination against Women and the Convention on the Rights of Persons with Disabilities, underscoring the imperative to ensure
there is accessible quality maternity care available for women and birthing people with disabilities' (ibid).
Harman is well aware of all of this, and touches on much of it at various points in the book, but is concerned for the most part with the role of international organisations and charities, and their interaction with states and vulnerable people. As a consequence, she covers a rather narrower set of themes, centred on the suggestion that women still far too often die when they don't have to 'not because of a lack of attention, science or evidence on what works for women's health, but because of the exploitation of women's health as a means of attaining and sustaining power in the world' (5-6) - a 'sick politics' of using and abusing women's health for political ends. This argument is presented in three parts. The first, 'Saving Mothers', 'looks at how women's health - specifically maternal healthcare - is used as a tool to gain and sustain power in the world'; the second, 'Exploiting Women', looks at 'the way women are exploited within health and foreign aid sectors, often as collateral damage in the wider delivery of healthcare'; and the third, 'SOS! (Same Old Solutions)', looks at how solutions focused on leadership, gender experts, and better data 'can fail in practice, and what can be done about them' (9). She then shifts her focus in the conclusion, 'The Driver and the Green Wave': development agencies, the international politics of aid, and the issues of leadership, gender experts and data drop away, and the emphasis turns to the role of movements at national or sub-national level aimed at protecting women's rights over their bodies, and specifically the right to abortion. The book concludes with a brief epilogue, addressed initially to students, then towards people who work in development- or gender-related organizations: in the light of the issues raised, what can you do next? You will learn a lot from the book about the global politics of women's health, and particularly about the ways - some good, some bad - in which global institutions and charities involved with it operate.
It is important to know at the outset that at some point in the process of writing the book, Harman consigned an 'academic' draft to a drawer and decided on a 'more accessible' approach (acquiring an agent and an editor in the process). The book accordingly makes very little use of academic monographs and specialist journals - and reasonably so, as they are not available to the majority of those to whom the book is aimed. It is still informed, of course, by her knowledge of such sources, and very extensive fieldwork experience, participation in a wide range of global health and other organisations, and systematic investigation of their structure, funding, policy, strategies and policy advice; and it draws directly or indirectly on over 360 interviews. However, just as academic publishing has conventions that authors need to follow, so does work aimed as this book is at a different and wider audience. There is no point in half measures, and Harman embraces the form wholeheartedly. Whether off her own bat, or as a result of guidance, she is bang on message with the key points of successful contemporary communication: employ 'popular' rather than 'academic' language ('all the rage'; 'mad for it', 'a bit of a cop out', 'pet peeve', and - my favourite - 'Gosh, no' (5), for example); use the first person singular; draw on your own experience, vividly described; establish your expertise at the outset ('as a professor teaching global health politics at a London university' (1), 'fifteen years researching global health politics ... As a professor of international politics, I had conducted research all over the world, ...'(2); and present issues that can appear large and rather abstract through concrete examples - in this case, short profiles of specific individuals involved. I don't have any problem with most of this: readers need to know something about the writer, and it is nigh on impossible, as you will know if you have tried, to get anyone to read a whole book (article? chapter?) as part of a programme of study these days. But the last point - the use of individual vignettes to get the argument across - is different. It is standard fare at the World Bank, who pioneered it in the World Development Reports, and central to the communication strategies of all leading development organisations, and Harman condemns them roundly for it. So, she reports that at a morning session of the UN's 2019 population conference in Nairobi, the CEO of a major international charity gave her seat on the platform to 'Sylvie', a young woman from South Sudan, who proceeded to deliver what Harman describes as a 'three-part narrative' of trauma: the trauma itself, its impact, and how she turned her life around with the help of the international charity. The audience 'lapped it up', but Harman herself 'zoned out' and could not recall the details later. 'After Sylvie had told her story,' Harman reports, 'she was silent. No one asked her a question, she did not respond to any general questions in the Q&A, she did not go off script, and I had no idea what would happen to her after she finished. Like the kid dancing on stage with the poster at a concert, her participation had been rehearsed, she had her moment in the spotlight, and then it went back to the more powerful woman being the centre of attention' (88-9). This leads into one of the most prominent arguments in the book:
'What happened with Sylvie and the panel is a new version of an old tactic: the selling of women's trauma as a means of eliciting an emotional reaction in the audience so they act on the wider issue. ... The selling of trauma stories is prevalent in fundraising in the aid and health sector because such individual stories are seen to resonate and connect with people. If you have an issue you care about, say cervical cancer, it is not enough to say that cervical cancer kills 342,000 people a year, and is the fourth most common cancer among women. ... What you need is a story to tell. One with the right amount of trauma and redemption' (90-91).
All well and good. But hang on a minute. Go back a few pages and you find that Chapter Four opens with a vignette of 'Amina', a Palestinian woman from Ramallah who gave birth at a checkpoint outside East Jerusalem (taken from a story published in 2005). That is all we learn about her. Like Sylvie, she is reduced to a one-dimensional trauma story, but unlike her, she doesn't experience redemption, or get to speak for herself at all. She is not aware that she is heading up this chapter, or that she will likely become a trope in innumerable student essays and presentations in the future. If Sylvie's case is one of exploitation, isn't this one too? And there is more. We learn that 'the reproductive choices of women like Amina were controlled by Israeli permits, checkpoints, border crossings and ever-shifting rules and requirements', as in any settler colonial regime. True. And it is a fair bet that most readers will readily assent to the idea that the government of Israel is the bad guy here. So it is. But what about the limits placed on the reproductive choices of women like Amina by widespread pressure from husbands and wider family to have large numbers of children, especially boys? Or the fact that abortion (widely and easily available in Israel, including to Palestinian women) is illegal except in extreme circumstances in Gaza and the West Bank, and so available only illegally and at risk to the woman? Or that contraception is frowned upon socially in the case of married women with no or few children? Does Amina have children already? Was she under pressure to produce (another?) son? Would she have preferred not to be pregnant in the first place, or to terminate the pregnancy once she conceived? We will never know. She has become 'woman-who-delivered-baby-at-Israeli-checkpoint'. And there are many such examples throughout the book.
So the method Harman adopts involves an element of contradiction, which readers will just have to live with. The book is best seen as a series of set pieces, all informed by rage which is entirely justified, and they add up to a powerful indictment of the politics of global women's health. The majority of them relate to the world of international aid related to women's health:
#1 Rwanda uses its truly remarkable record on women's health, complemented by gender parity (in fact a clear female majority) in parliament, as a form of 'soft power': it has become the darling and favoured partner of international donors. Harman comments: 'Using women's health as a tool of soft power is not necessarily a bad thing: it would be great if all the countries in the world gained their standing, recognition and good diplomacy from helping women. But there is a sinister side to this. Rwanda uses its standing on women's health to 'healthwash' the unseemly, more murderous part of Rwandan politics' (21). International donors have decided to live with this, and Harman does not say they are wrong to do so.
#2 International aid in the 1990s was highly selective in its focus on 'saving mothers' - and babies - to the exclusion of other issues, such as the punitive impact on women of structural adjustment and the burden of reduced support and extra work it imposed. Along came the MDGs, but with an embedded compromise: 'in the new MDG era ... the focus would be on maternal health, not sexual and reproductive health. In other words, they took out the part of women's health the majority of governments in the world seek to restrict: abortion and contraception' (36). And when massive financing was directed towards HIV/AIDS, especially with US President George W. Bush's $100 billion President's Emergency Plan for AIDS Relief (PEPFAR) in 2003, it went along with the promotion of family values, abstinence, and monogamy, and left 'undeserving' drug users and sex workers out. Beyond this, the focus broadened to cash transfers paid directly to mothers, conditional on children turning up to school and to clinics for health checks and vaccinations. Such policies reflected gender stereotyping and added to women's already extensive responsibilities but, as Harman acknowledges, they worked (39).
#3 The 2015 MDGs included a target (3.7) on sexual and reproductive health: to ensure universal access by 2030 to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies, but access to safe abortion remained strictly off limits. And in sharp contrast to action on AIDS, all Republican Presidents from Reagan onwards uphold (and all Democratic Presidents overturn) the 'Mexico City Policy' (that being the site of the 1984 UN Conference on Population and Development), or global gag rule, which stipulates that no organisation abroad in receipt of US funds for family planning and reproductive health can discuss or conduct abortions. Trump took it further in 2017, extending it massively to UN agencies, and halting US funding for the UN Population Fund into the bargain (49-52), thereby reducing materially resources available for the full range of policies addressing sexual and reproductive health; Biden reversed it. What will happen next remains to be seen. The reduced availability of safe abortion does not reduce the number of abortions, it simply increases the number of unsafe ones. So with one hand the US under Republican presidents in particular and the international donor community generally act to reduce maternal mortality, with the other they place a leading cause off limits. Harman's extended discussion of the causes and consequences (53-68) is valuable.
#4 Amina's story (above) introduces a discussion on the politics of maternal health in zones of conflict in Gaza, the West Bank, Syria and Ukraine, cases 'united by an effort to control, curtail or destroy women's health services by one side of a dispute in order to defeat the other' (71). One telling statistic among many others is that Israeli settlers living in the West Bank in 2020 maternal mortality was nine times lower than for Palestinian women living there (75); and the deliberate targeting of hospitals that Harman records in Ukraine and in Syria has repeatedly occurred in Gaza too since the Hamas military operation of 7 October 2023.
#5 Sylvie's appearance at the UN (above) introduces the theme of 'the selling of women's trauma as a means of eliciting an emotional response in the audience so they act on a wider issue' (89). Turning to fundraising leaflets and campaigns, Harman comments: 'Look at those pictures. Chances are they are a woman, girl or boy, most likely with black or brown skin. They are rarely a man, and never a white man. Perhaps with good reason: these images represent the recipients of aid money. But ask yourself what they represent about the person, the country they live in, the charity, and the setting or context. What is problematic about these images is how the women in them are often defined by their trauma - whether they are still in need of help or have already been empowered - and the context in which these pictures are taken. The unsettling part is not just the use of such stories, but the fact that women and girls are approached for their stories when they seek out healthcare; and that it is the very organisations who are supposed to help vulnerable women and girls access health who are doing the exploitation (89-90, emphasis mine). Harman profiles the case of Médecins Sans Frontières (MSF), recounting that a photograph taken for purposes of publicity of a teenage victim of major sexual assault became available as a commercial stock image, on sale for £375 (93), along with thousands like it, and reporting a campaign launched in May 2022 to persuade MSF to halt the use of such images and their commercialisation (by photographers and agencies, as she notes, as they, not MSF, hold copyright). To judge by their website MSF may have changed its practice somewhat.
#6 In 2019, during an Ebola outbreak in the Democratic Republic of Congo (DRC) evidence emerged of the sexual harassment, abuse and exploitation of women and girls caught up in it by WHO health workers sent to help them. When an independent investigation was launched, more than fifty victims of abuse came forward, including women employed locally by the WHO itself (104-6). This was far from an isolated case: multiple cases were reported in the 1990s; and in February 2018 the Times reported systematic abuse by Oxfam staff in Haiti from 2011 onwards; similar abuses in the Horn of Africa subsequently came to light. The WHO was particularly slow to take action, and its director-general never took responsibility.
#7 All major global health initiatives depend on 'last mile' community health workers, 'mostly women and rarely paid properly' (154), and the global response to HIV/AIDS in the early years of this century is offered as a case in point. The efforts of international agencies and charities alike depend heavily on poorly paid or unpaid volunteers, caring for the sick and monitoring and reporting the incidence and spread of disease. The WHO puts the number at over 34 million, but the number is much higher than such formal estimates suggest.
#8 Three frequently canvassed solutions to the dismal record on global women's health - appointing women to leadership roles, employing 'gender experts', and developing better data - have yielded disappointing results. There are a small number of women in leading roles in global women's health (notably, the philanthropist, Melinda French Gates), and women 'hold 40 per cent of board seats of the most influential public and private health organisations in the world'. But 58 per cent of these have never had a female CEO, and 51 per cent have never had a female chair of the board (171). For the very top jobs, better-qualified women are frequently overlooked, losing out to more politically connected men: 'The trick that all working women come to realise at some point in their professional lives is you can work as hard as you can, do all the networking and be more qualified for the job, but you will never be seen as the most qualified candidate' (184). Gender experts are too often under-resourced, assigned trivial administrative tasks, used as window-dressing, ignored on major issues, and kept at arms length by tactics such as filibustering, which Harman illustrates with the 'Gender Filibuster Bingo Card' (201). As regards data, it can be transformative, and gender-relevant data is now collected much more widely than in the past. But its availability is still limited by government capacity, prejudice and discrimination, narrow and incorrect assumptions, and the sheer difficulty of getting down to local and community levels. There is a darker side, too - personal app-related data can be harvested and sold by Facebook, for example, handed over to the police, and used - as illustrated here - in successful prosecutions for illegal abortion (222-3).
At this point Harman turns her attention away from international agencies and charities, to focus in a brief conclusion on rights to safe and legal abortion - under threat in the United States, and recently won in Argentina. In each case, the focus is on grassroots action - the volunteer who drives strangers three or more times a week from Mississippi to Illinois to keep access to legal and safe abortion open, and the campaigners who won a change of law in Argentina in December 2020. Harman concludes this chapter, as she does the previous one, with a simple message: listen to women, and believe them.
This sets up the epilogue, which works well both as a conclusion, as it covers the main themes of the book, and as a graduated set of practical recommendations starting from the point that feeling hopeless gets us nowhere, avoiding guilt-tripping ('do absolutely nothing if you don't want to', 249), insisting again on the imperative need to believe women 'when they tell you they are sick, need money, have an idea, are being exploited or are injured pain' (255), and leading up to what is effectively a checklist code of good practice for professionals in the health aid industry.
So what do I make of the book overall? I have one grumble, and one caveat. The grumble relates to the couple of chapters slipped in midway through (7 and 8, 120-50) which address the violence to which health workers are subject, and the issue of burnout, both predominantly with reference to the UK. They don't fit well with the rest of book, and their placing seems arbitrary. Worse, this is the only point where Harman's exclusive focus on women appears to be seriously misleading. She moves from the fact that 70 per cent of front-line health workers are women to assert that: 'To take this issue seriously, violence against health workers needs to be seen for what it is: gender-based violence' (133). I think that this is a distortion. For example, a YouGov survey from 2022 reports that men are more likely to say they have experienced violence from patients than women are; 'Male and female NHS patient-facing healthcare workers report differing experiences of violence and aggression from patients. While a third (36%) of male healthcare workers report experiencing violence from a patient at least once a year, this figure falls to 28% of women. Similarly, a fifth (20%) of men say they’ve experienced violence from a patient’s family member, compared to 14% of women. ... However, when it comes to aggressive behaviour, the numbers are more even. Around the same proportion of male and female NHS patient-facing NHS workers say they have experienced aggressive behaviour from a patient at least once a year, 69% and 66% respectively. The figures are also similar for aggressive behaviour from a patient’s family member – 62% of men and 64% of women say they experience this at least once a year' (https://yougov.co.uk/health/articles/40710-three-10-healthcare-workers-say-they-experience-vi). And Harman reports the case of a health worker assaulted in Manchester in gender-neutral language, without disclosing that the victim was a man in his fifties (127, and see https://www.independent.co.uk/news/uk/crime/nhs-worker-assault-hospital-jail-salford-royal-infirmary-manchester-a9487526.html, 28 April 2020).
The caveat is this: the focus on institutions and charities concerned with global health inevitably gives only a partial picture of the dynamics of global development as they relate to women, or to orientations towards women on the part of the full set of global institutions. Harman does not say that the institutions and charities she discusses bear the primary responsibility for the parlous state of women's health in large parts of the world. As her text repeatedly reflects, it is primarily a consequence of the huge disparities of wealth and income across and within countries, along with social patterns which vary widely, but still predominantly subject girls and women to the authority of men. Realistically, they cannot substitute for the universal health coverage and strong indigenous health systems that Souza and his fellow authors identify as essential, let alone transform the societies in which they operate. This confronts them with recurrent dilemmas that she frequently addresses. But one particular set of issues is missing in her account. Taken as a whole, action on women's health on the part of international organisations goes way beyond a concern with maternal mortality and HIV/AIDS, and this is because the leading global agencies - the World Bank and the IMF - do not focus exclusively on women as mothers. Quite the contrary. The primary driving force behind their genuine concern with women's health (and education) is their desire to see more women productively employed in the global labour force: young women are potential workers before they are potential mothers. This is a caveat, rather than a criticism, because it lies outside Harman's chosen topic. And it is worth noting, when we are urged, fairly enough in context, to listen to women, that international organisations with an economic remit are happy hunting grounds for neoliberal feminists, and that the Managing Director of the IMF and her first deputy are both women; the President of the European Central Bank is a woman; the President of the ultra-neoliberal European Commission and more than half the Commissioners are women; the right-leaning ex-Bank of England British Chancellor of the Exchequer is a woman, as are half her ministerial team, and a majority of her civil service management team, and so on.
References
Bohren, Meghan A. et al. 2024. Towards a better tomorrow: addressing intersectional gender power relations to eradicate inequities in maternal health, eClinicalMedicine, 67, January.
Souza, João Paulo et al. 2024. A global analysis of the determinants of maternal health and transitions in maternal mortality, Lancet Global Health, 12, 2, 306-316.
Sheikh, Jameela, et al. 2024. Vulnerabilities and reparative strategies during pregnancy, childbirth, and the postpartum period: moving from rhetoric to action. eClinicalMedicine, 67, January.
Vogel, Joshua et al. 2024. Neglected medium-term and long-term consequences of labour and childbirth: a systematic analysis of the burden, recommended practices, and a way forward, Lancet Global Health, 12, 2, 317-330.