By Laura Dean*, Kate Hawkins, Rachel Tolhurst, Eleanor Macpherson, Lee Haines, Daniela Ferreira, Angela Obasi and Sally Theobald
Zika is a disease exacerbated by poverty – risk is not spread uniformly – those who already face extreme social marginalisation are more vulnerable. If you live in a poor area, such as a Favela; Ghetto etc., with limited access to running water, sanitation, rubbish disposal, health facilities and education regarding how mosquitoes reproduce you are likely to be more at risk to vector-borne diseases. Over the next few weeks and months we are likely to witness the release of much more information that keeps Zika being discussed. This blog explores three key, inter-related issues in relation to Zika: gender and power; context and vulnerabilities; and stigma, disability and pregnancy. Zika particularly focuses a spotlight on gender and disability in low and middle income settings (LMICs). In the lead up to International Women’s Day, we believe that health systems researchers should grasp the opportunity to think about how they can ‘build back better’ health and social systems in the wake of this and other epidemics.
Delaying Pregnancy: Gender, power and sexual and reproductive rights
Richard Horton, the Editor-in-Chief of The Lancet, recently highlighted gender as the neglected area in global health, pointing out that it receives inadequate focus within the Sustainable Development Goals (SDG). Much of the messaging that has come in the wake of the Zika epidemic in the Americas seems similarly gender blind.
In her recent blog, Clementine Ford presents the predicament that governments face when associations are presented with potentially disabling congenital conditions (microcephaly), a virus epidemic (Zika), and pregnancy. A recommendation to delay pregnancy for two years, as is being suggested in countries like El Salvador, seems disconcerting to those of us familiar with contexts where abortion is illegal and/or stigmatised and there is a high unmet need for contraception. Sadly, challenges in realising sexual and reproductive rights for women in these contexts are not unique to the Zika epidemic.
There is a need for greater collaborative thinking between decision makers working within patriarchal systems, scientists, and those who these decisions are most likely to impact upon, particularly women of reproductive age. In responding to the growing evidence that suggests a causal link between Zika virus and microcephaly, there is a need to re-open, encourage and maintain focus on debates regarding sexual and reproductive health and rights within the Latin American region. Not only should it be a woman’s right to choose if and when to get pregnant, based on accurate information, but also she should be granted access to the services that enable her to make this informed choice.
Context Matters: Vulnerabilities and Social Marginalisation
Zika virus, and other insect-borne diseases like Dengue and Chikungunya, highlight the troubling health inequity that is based on deprived living conditions. Within Brazil’s favelas, there is a large proportion of single parent families, the majority of which are headed by women. These households are more likely to experience perpetual cycles of poverty as a result of the economic shock of disease. In addition, where children are born with potentially disabling impairments they are often further isolated by limited support or social protection from the government and become reliant on seeking support from the private non-governmental sector if and when it exists. For example, in their recent blog Reed Johnson and Rogeiro Jelmayer present the story of Alice, a baby born with microcephaly, whose parents now ‘spends one sixth of their income on a battery of medications and treatments for Alice’ in addition to the opportunity and travel costs associated with attending medical appointments. Families living in favelas are more vulnerable to arboviruses than those families living in apartment towers that are expensive, well built, screened and elevated well above primary mosquito habitats. This is inequitable.
Currently, Zika outbreak management is focused on mosquito control strategies aimed at reducing mosquito densities (larviciding and fogging) and bite prevention by female adult mosquitoes (repellents). Research into vaccine development and new diagnostic tools is also a global priority. Inequitable vulnerabilities also need to be considered alongside medical and technological advancements if we are to build better social and just systems and environments that reduce the risk of disease.
Disability related stigma: Reinforcement and creation
Since there has been such an increase in media coverage on Zika, several reports of disconcerting new stigmas in poor areas in Brazil have emerged, for example, pregnant women being made to feel stupid for being pregnant. In addition, men have been stigmatised for fathering a ‘Zika baby’ – further reinforcing stereotypical norms related to virility, fertility and machismo – and in some cases leading to the abandonment of their partners and children.
Abandonment of mother and baby due to a child being born with a disabling impairment is not a new phenomenon, nor is it unique to microcephaly in the context of Zika. However it provides another clear example of extreme social marginalisation and stigmatisation that disease outbreaks can create.
In part this is due to the portrayal of Zika and microcephaly within the media. Currently, there is no proven causal link between microcephaly and Zika, rather associations are hypothesised within the Brazilian context. Regardless of causal link or pathway, there is need to think critically about the portrayal of microcephaly and how this can label children ( in some instances before they are born), and (i) reinforce negative social constructs of disability and (ii) stigmatise pregnancy itself undermines one of the most fundamental reproductive rights that women have. The World Health Organisation describes microcephaly as a condition where a baby is born with a small head or the head stops growing after birth. Microcephaly can cause varying degrees of impairment and grouping all or indeed any babies born with microcephaly as ‘damaged’ is a dangerous branding. Nevertheless, babies born with microcephaly, particularly when located in the poorest regions, are likely to need additional access to medical services and social interventions. This cannot be forgotten as causality between microcephaly and Zika virus are further investigated, and focus should also be given to the provision of support and inclusive development for individuals living with microcephaly regardless of cause.
It is our role as health practitioners, researchers and policy makers, to think about what this means for people living with microcephaly and indeed other disabilities and what we can do to create more supportive, enabling and inclusive environments. This is likely to need multi-disciplinary approaches, with a need for social mobilisation. As an immediate priority we should reject the label ‘Zika baby’, just as the term ‘AIDS baby’ was consigned to the dustbin of medical history.
The way forward for gender and disability and the Zika epidemic
Responding appropriately to the Zika epidemic will require us to navigate the landscape of complex reproductive health messaging and service provision. It must be based on strong community engagement, adjustments within the health system to make service more equitable and accessible, and realistic and pragmatic thinking about policy implications, which may require a shift from ideology to evidence and rights. We would argue that this can only occur if new partnerships between epidemiologists, virologists, clinicians, gender specialists, disability rights activists, vector biologists, sociologists, psychologists, and health systems researchers are forged and inform policy. Multi-disciplinary approaches are essential. Furthermore, globally stakeholders who are most affected by disease epidemics need to have their voices heard and drive the questions on equity. It is critical to remember that as vaccines are developed, and scientific links are proven/disproven, human rights abuses related to disability and sexual and reproductive healthwill remain globally and are often felt most by those who are already socially marginalised. This is unacceptable and we must set aside resources to tackle these issues.
* Laura Dean is a research assistant and PhD candidate at theLiverpool School of Tropical Medicine. Her research focuses on equity andhealth systems, with specific interests in gender, disability and community ledinterventions. She currently works with the COUNTDOWN consortium on exploringways that control and elimination of Neglected Tropical Diseases can be moreinclusive and equitable.
By Kate Hawkins, Research in Gender and Ethics: Building stronger health systems (RinGs)
When you work on health there are many international days which crop up during the year. Sometimes it’s easy to disconnect from their origins and meaning. It is International Women’s Day in a month’s time. So I thought it might be useful to reflect on what they day has meant and how we might celebrate it as people who have a commitment to health systems.
Whilst we tend to think of International Women’s Day as an initiative of the United Nation its roots are in women’s labour organizing. “We’d rather starve quick than starve slow,” was one of the slogans used by the International Ladies’ Garment Workers’ Union (the ILGWU) during their strike of 1909 in America. The ILGWU were fighting for improvements in their working conditions, as the factories that employed them were essentially sweatshops.
The strike was led mainly by young, immigrant workers – Jewish women from Russia, Poles, and Italians who conducted their meetings in English, Yiddish and Italian. The call to strike was actually made by a 15-year-old Ukraine-born girl worker, Clara Lemlich. Factory workers were joined in their struggle by some middle class women who offered financialand practical support.
In striking they confounded the mainstream, male labour movement, who were skeptical about their ability to organize themselves, and they defied the state (they were unfairly arrested by the police and beaten by hired local thugs). The ILGWU accepted a settlement in 1910 that improved things like working hours but didn’t give their union recognition. In 1909 the Socialist Party of Americacelebrated International Women’s Day for the first time in remembrance of the strike.
To say that the women were striking for their lives is no exaggeration. In 1911, 146 women employed in a clothing factory died when a fire broke out in their workplace – the Triangle Shirtwaist Factory – the number of deaths was high because of the poor health and safety practices that were employed there.
Promotion of the concept of International Women’s Day beyond the United States was taken up by Clara Zetkin. Later to be adopted by the United Nations (in 1975) with a General Assembly Resolution. However, for many woman workers around the world occupational environments still constitute a hazard to health.
Thinking and acting together to make change
Whilst many people working in international development and global health may celebrate International Women’s Day we don’t often talk about its roots in collective organizing, intersectional struggle, and a radical redefinition of the possible. Thinking about the creation of the Day reminds us that gender equity is not just a nice idea, it can literally be lifesaving. Remembering this heritage is one way of sparking new ways of thinking and new partnerships to address the seemingly intractable issue of gender inequity. This is especially timely as one of the themes of the upcoming Global Symposium is Equity, Rights, Gender and Ethics.
The theme of this year’s International Women’s Day is “Planet 50-50 by 2030: Step It Up for Gender Equality”, with a focus on building momentum for the implementation of the new Sustainable Development Goals. This year we have asked Health Systems Global to celebrate International Women’s Day by running a month where they promote content on health systems and gender equality in the form of blogs, webinars, and a Twitter chat. You can find out more about the Twitter chat on this blog.
The blog series is open to all Health Systems Global members and it would be great to get inputs from a range of countries and perspectives. We hope that there will be active participation across all of the Thematic Working Groups. Please do get in touch and let us know how you would like to contribute.
If you can think of any other ways that we can share information on health systems and gender we are open to your ideas and we look forward to hearing from you.
Photo credits:
Two strikers during the 1909 “Uprising” courtesy of http://labormovement.blogs.brynmawr.edu/ a site dedicated to the International Ladies’ Garment Workers’ Union
At a rally by the International Ladies’ Garment Workers’ Union at the site of Triangle fire, placards in English and Spanish naming Domsey Fiber include “We shall not forget” and “Trabajadores uniodos hamas seran vencidos” pointing to the continuing struggles of immigrant workers.
Photographer: unknown, 1990, Kheel Center
Recently we both attended a RinGs webinar on how to do gender analysis. This is part of the capacity strengthening activities of the project. It is really nice to take some time to hear from colleagues working on health systems around the world and get some space to think through how we can work together to strengthen a gender analysis. RinGs is developing a great deal of detailed material on this topic so we thought we would keep this short and give you our ten things to bear in mind about gender and health systems research.
1.Gender is a key social stratifier: As a power relation it affects vulnerability to ill health and the decision making space and economic power that people have to tackle illness. Access to health services can be effected by gender, for example, women may have less money to pay for health care and find it difficult to travel to a health care centre. On the other hand, sometimes health care centres can be too tailored to women, which puts men off attending.
2.To strengthen health systems we need to pay attention to gender: It is important to understand how health systems components interact with each other, how gender plays a role in each of these, and how to address these gender issues in health systems strengthening activities in order to improve health and social outcomes. Including gender analysis in health systems research help maximise the effectiveness of programmes, lead to better research recommendations, more strategic interventions and programmes and more effective policies.
3. As health systems researchers we need to recognise gender: Expressions of gender inequity -whether in the relations between women and men or within organisations -need to be recognised and addressed in order to redress discrimination and ensure interventions in health involve and benefit the disadvantaged.
4. Sometimes gender issues are rendered invisible: For example, terms like Community Health Worker, village health committees, insurance policies appear gender neutral and yet they are gendered. When we disaggregate data and analyse context and relationships these gendered aspects can come to the fore.
5. There are still issues and confusion about separating gender and sex, especially in analysis: ‘Being’ female and ‘being’ a woman are two very different sort of being. Yet in data analysis, for example, gender disaggregation means separation into male and female. It is not uncommon to see such variables as ‘Sex/Gender’.
6.We need to look beyond the individual: It is important to think about gender relations between couples, families and households. But gender analysis is also about how society is structured, the norms and institutions that guide things and access to resources that flow from this.
7.We need to take account of gender-fluidity: Gender isn’t fixed, it changes across time and across contexts. Looking at gender in combination with race, class and other forms of inequality enhances the analysis.
8. Gender frameworks can help: RinGs has collated what they consider the top ten gender frameworks on their website. They can help us think through what constitutes power gendered relations and how power is negotiated and changed.
9.We should also think creatively about the methods that we use: For example, we could employ social networking analysis of gender issues in healthsystems research in addition to other available tools.
10. Building capacity goes beyond the individual: Ensuring that gender infuses questions about research design, data collection and analysis is important. Researchers need to think carefully about their own positionality. However, we also need to look to those political, social and economic structural barriers that prevent a focus on gender in the first place. What can we – as health systems researchers – do to overcome these?
We call upon our colleagues in RinGs to use the comments function below to add to the list of gender-related points to keep in mind when you are doing health systems research and to keep the conversation live!
*Prof BSC Uzochukwu is the deputy coordinator of the Health Policy Research Group, College of Medicine, University of Nigeria, Enugu-campus. He is a member of the Resilient and Responsive Health System Consortium (RESYST) and Board member of Health Systems Global (HSG).
Recently we both attended a RinGs webinar on how to do gender analysis. This is part of the capacity strengthening activities of the project. It is really nice to take some time to hear from colleagues working on health systems around the world and get some space to think through how we can work together to strengthen a gender analysis. RinGs is developing a great deal of detailed material on this topic so we thought we would keep this short and give you our ten things to bear in mind about gender and health systems research.
1.Gender is a key social stratifier: As a power relation it affects vulnerability to ill health and the decision making space and economic power that people have to tackle illness. Access to health services can be effected by gender, for example, women may have less money to pay for health care and find it difficult to travel to a health care centre. On the other hand, sometimes health care centres can be too tailored to women, which puts men off attending.
2.To strengthen health systems we need to pay attention to gender: It is important to understand how health systems components interact with each other, how gender plays a role in each of these, and how to address these gender issues in health systems strengthening activities in order to improve health and social outcomes. Including gender analysis in health systems research help maximise the effectiveness of programmes, lead to better research recommendations, more strategic interventions and programmes and more effective policies.
3.As health systems researchers we need to recognise gender: Expressions of gender inequity -whether in the relations between women and men or within organisations -need to be recognised and addressed in order to redress discrimination and ensure interventions in health involve and benefit the disadvantaged.
4. Sometimes gender issues are rendered invisible: For example, terms like Community Health Worker, village health committees, insurance policies appear gender neutral and yet they are gendered. When we disaggregate data and analyse context and relationships these gendered aspects can come to the fore.
5. There are still issues and confusion about separating gender and sex, especially in analysis: ‘Being’ female and ‘being’ a woman are two very different sort of being. Yet in data analysis, for example, gender disaggregation means separation into male and female. It is not uncommon to see such variables as ‘Sex/Gender’.
6.We need to look beyond the individual: It is important to think about gender relations between couples, families and households. But gender analysis is also about how society is structured, the norms and institutions that guide things and access to resources that flow from this.
7.We need to take account of gender-fluidity: Gender isn’t fixed, it changes across time and across contexts. Looking at gender in combination with race, class and other forms of inequality enhances the analysis.
8. Gender frameworks can help: RinGs has collated what they consider the top ten gender frameworks on their website. They can help us think through what constitutes power gendered relations and how power is negotiated and changed.
9.We should also think creatively about the methods that we use: For example, we could employ social networking analysis of gender issues in healthsystems research in addition to other available tools.
10. Building capacity goes beyond the individual: Ensuring that gender infuses questions about research design, data collection and analysis is important. Researchers need to think carefully about their own positionality. However, we also need to look to those political, social and economic structural barriers that prevent a focus on gender in the first place. What can we – as health systems researchers – do to overcome these?
We call upon our colleagues in RinGs to use the comments function below to add to the list of gender-related points to keep in mind when you are doing health systems research and to keep the conversation live!
*Prof BSC Uzochukwu is the deputy coordinator of the Health Policy Research Group, College of Medicine, University of Nigeria, Enugu-campus. He is a member of the Resilient and Responsive Health System Consortium (RESYST) and Board member of Health Systems Global (HSG).
Sally Theobald, Rosemary Morgan, Kate Hawkins and Sassy Molyneux
Human Resources for Health: 57
In this commentary, we discuss a photography competition, launched during the summer of 2014, to explore the everyday stories of how gender plays out within health systems around the world. While no submission fees were charged nor financial awards involved, the winning entries were exhibited at the Global Symposium on Health Systems Research in Cape Town, South Africa, in October 2014, with credits to the photographers involved. Anyone who had an experience of, or interest in, gender and health systems was invited to participate. Underlying the aims of the photo competition was a recognition of the importance of participation of community members, health workers and other non-academics in our research engagement and in venues where their perspectives are often missing. The competition elicited participation from a range of stakeholders engaged in health systems: professional photographers, project managers, donors, researchers, activists and community members. In total, 54 photos were submitted by 29 participants from 15 different nationalities and country locations. We unpack what the photos suggest about gender and health systems and the pivotal role of community-level systems that support health, including that of close-to-community health providers. Three themes emerged: women active on the frontlines of service delivery and as primary unpaid carers, the visibility of men in gender and health systems and the inter-sectoral nature and intra-household dynamics of community health that embed close-to-community health providers. The question of who has the right to take and display images, under what contexts and for what purpose also permeated the photo competition. We reflect on how photos can be valuable representations of the worlds that we, health workers and health systems are embedded in. Photographs broaden our horizons by capturing and connecting us to subjects from afar in seemingly unmediated ways but also reflect the politics, values and subjectivities of the photographer. They represent stereotypes, but also showcase alternate realities of people and health systems, and thereby can engender further reflection and change. We conclude with thoughts about the place of photography in health systems research and practice in highlighting and potentially transforming how we look at and address close-to-community providers.
Introduction
Research in Gender and Ethics (RinGs): Building Stronger Health Systems is a partnership across three health systems research consortia1, developing a platform for learning and research on gender, ethics and health systems. During the summer of 2014, RinGs launched a photography competition to explore the everyday stories of how gender plays out within health systems around the world. Given that gender is often not considered relevant to health systems or understood in simplistic ways 1], we hoped that the photography competition would generate visual stories that would inspire imagination and provoke contemplation among health system researchers and practitioners about what gender means for their work.Photos, like written outputs, are representations of the social and ideological worlds we, health workers and health systems are embedded in. As such, they are an important data source to communicate and understand complex issues and diverse contexts 2, 3], particularly in the increasingly visually saturated and globalized economy we are situated in. Photographs can broaden our horizons by capturing and connecting us to subjects from afar in seemingly unmediated ways. However, they do not simply mirror reality but also reflect the politics, values and subjectivities of the photographer, through what they choose to highlight and how they frame their images. They can either represent stereotypes or provide an opportunity to showcase unique and vivid alternate realities of people and health systems, and thereby engender further reflection and change.In this commentary, we reflect on the photos submitted and the ensuing judging process and email dialogue with participants who reacted to the photo competition. We are a team of health systems researchers and a communications and research uptake manager. We have little experience in photography beyond personal use and no expertise in the various academic fields that engage with photography, beyond work with participatory photography as a research methodology. As researchers, our incentive structures may prioritize academic publications over other ways of supporting and documenting community voice and social change. Nonetheless, we strongly feel that photography is an important medium that health systems researchers and practitioners must critically engage in.Within this paper, we seek to unpack what the photos suggest about gender and health systems and the pivotal role of community-level systems that support health, including that of close-to-community health providers. The latter include “health workers who carry out promotional, preventive and/or curative health services and who are often the first point of contact at community level…[and] are strategically placed as the interface between health systems and the communities they serve” 4]. In examining our experience of the photo competition, we discuss our interpretation of the narrative and politics underlying the images and the potential of photography to better understand and therefore inform more effective and equitable ways of supporting close-to-community provision of health services. We describe the photo competition, analyse the three main themes that emerged, consider the ethical issues that arose and conclude with thoughts about the place of photography in health systems research and practice.
The photo competition
The RinGs photography competition was advertised widely through twitter, email list serves and several websites between 22 July and 1 September 2014. The deadline for entries was 1 September 2014. The competition was particularly targeted at health systems researchers within our own networks and potential Global Symposium on Health Systems Research participants. The aim of the competition was to capture the everyday stories of the ways that gender plays out within health systems around the world. In particular, we were looking for images which challenged stereotypes, encouraged the viewer to learn more and act differently, and which respected the integrity of any people who may be photographed. We welcomed images of people of all genders from all areas of the health system and from all around the world 5]. While advertising the competition, links were included to discussions on the ethics of photography in international development, which dealt with issues of consent, motives, respect and portrayal of subjects. Participants were asked to describe the level of consent obtained for each submission, and photos which were taken without consent were not considered. Additional submission requirements and information required from participants is presented in Table 1.
Table 1: Submission requirements and information supplied by participants
Submission requirements
Information supplied by participants
1. Size: at least 1 MB
1. Name of participant
2. Print resolution: 300 dpi
2. Participant’s email
3. Format: JPEG or tiff only
3. Participant’s phone
4. Landscape and portrait images are acceptable
4. Title of photograph
5. Although some digital enhancement is acceptable, we cannot accept images that have been digitally altered to change what is portrayed
5. Location (country and city/town/village where the photograph was taken)
6. The date (if unknown, please provide the year) each photograph was taken
7. The level of consent provided from any people pictured in the photo (see informed consent guidelines for more information)
While no submission fees were charged nor financial awards involved, it was advertised that the winning entries would be exhibited at the Global Symposium on Health Systems Research in Cape Town, South Africa, in October 2014, with credits to the photographers involved. In addition, RinGs stated that it would use the images to illustrate our website and other published materials with credit to the photographers. Based on learning from the competition process, we removed this last condition, as discussed later.Up to three photos could be submitted via email to RinGs and were displayed online through a Flickr account. In total, 54 photos were submitted by 29 participants of 15 different nationalities and country locations (see Table 2). We were pleased to see the breadth of geographic participation and that so many of the participants were female. The repository of images was actively disseminated via social media by the RinGs steering committee to stimulate interest and discussion on the subject matter among health systems researchers and practitioners.
Table 2: Summary of photo competition participants’ profile
Gender
Nationality
Photo location
Female
17
United States
6
Nigeria
5
Male
11
Kenya
4
Uganda
4
Unknown
1
India
3
India
3
Total
29
Nigeria
2
United States
3
Indonesia
2
Indonesia
2
United Kingdom
2
Mozambique
2
Ireland
1
Kenya
2
Germany
1
Cambodia
2
Cameron
1
Bolivia
1
Uganda
1
Ethiopia
1
South Africa
1
Tanzania
1
Cambodia
1
Guinea Bissau
1
Myanmar (Burma)
1
Bangladesh
1
China
1
South Africa
1
Taiwan
1
Ghana
1
Unknown
1
Total
29
Total
30
Underlying the aims of the photo competition was a recognition of the importance of participation of community members, health workers and other non-academics in our research engagement. We saw the competition as one way to increase their visibility at an international health systems research conference where the perspectives of communities, health workers and other non-academics are often missing. Anyone who had an experience of, or interest in, gender and health systems was invited to participate.The competition elicited participation from a range of stakeholders engaged in health systems: professional photographers, project managers, donors, researchers, activists and community members. Two of the submissions that were given an honourable mention were photovoice entries, where community members themselves got behind the lens to document and narrate their stories; these photos where submitted by researchers who were involved with the photovoice projects. One highlighted women in street performance peer education activities for maternal health in Uganda, and another profiled a woman from a marginalized community learning how to use a camera to document community resilience in the Sundarbans, an ecologically vulnerable region in India.All photos were judged on the basis of their content (their relevance to the subject), their ability to tell the story of gender and health systems and the technical merit of the photo by five judges. The judges included academics working on gender and health systems drawn from the RinGs steering committee, and a research communications consultant independent of RinGs who has extensive experience in international research on women’s empowerment. Each judge scored the photos on a scale of 1 to 3 (from not meeting the criteria to fully meeting the criteria) in relation to the three criteria listed above. The scores were then totalled and averaged across the five judges. The photos were subsequently ranked according to their overall score. All photos that received a score of 2.3 and above were given an honourable mention.As stated above, photos often reflect the politics, values and subjectivities of the photographer, through what they choose to highlight and how they frame their images. How photos are interpreted by the viewer is also subjective, grounded in his/her own social and ideological world. The judges therefore interpreted the photographs in a way that was congruent with their own knowledge, backgrounds and interests, which may or may not have matched the intent of the photographer or resonate with other viewers. All the judges had expertise relevant to gender and community health systems; three were based in high-income countries (the United Kingdom and the United States) and two were based in a low- and middle-income country (Kenya).
One winner was unanimously selected 6], and 15 photographs were given an honourable mention by the judges 7]. The winning photo was submitted by AMREF Health Africa and is a professional portrait of an older woman who used to be a traditional birth attendant, who has retrained as a midwife in Uganda (Figure 1). The image resounds with the strength, dignity and confidence of a woman proud of her contributions despite the challenges faced. She shines like a ray of hope parting the stormy clouds of circumstance. As the photograph is taken from below, we look up to her with respect, which is in contrast to the many photos where we look down on women. She is wearing the gloves and a uniform of a female vocation and profession that is under negotiation and transformation. The photo was selected because it presents a strong, positive image that pushes boundaries. It takes a conventional role and presents it in an unconventional and affirming manner, while valuing women as wise and weathered agents, rather than objects of passive beauty.
Figure 1 Winning photo: The power of a midwife. Photo credit: this photo was taken during a collaboration between the Guardian UK and AMREF Health Africa. Caption: the traditional birth attendant, trained as a professional midwife, is leading the maternal and neonatal care revolution in Africa. What was once a neglected role of women has now taken the attention of international health NGOs and global policymakers working toward a healthier Africa. Photo location: Katine, Uganda. Images submitted and the themes they portray
Women active on the frontlines of service delivery and as primary unpaid carers
Women on the frontline of health service delivery was a theme portrayed by 17 photos. This is representative of global statistics that show that human resources for health are gendered. In many countries, women make up more than 75% of the health workforce, primarily at the lower tiers closest to communities 8]. Many of the 17 photos feature women working in communities as volunteers or community health workers, highlighting their roles in serving other women primarily through community or preventive services. This included being trained as peer educators in Nigeria, as Kaders registering women and children in Indonesia, weighing children in Uganda, or immunizing children in Ethiopia. Often, these tasks were undertaken with vigour and humour, as shown by the traditional birth attendants (TBAs) in Guinea Bissau who are pictured in a line seemingly staring down the photographer (Figure 2).
Figure 2 Traditional birth attendants pose after newborn training in Guinea-Bissau.
Photo credit: Polly Walker. Photo location: Buba, Quinara Region, Guinea-Bissau.
Women’s role as unpaid carers for family members was also prominent 9, 10]. Caring for sick or elderly family members is often not recognized as work by the health sector. Many photos documented women waiting for service at health systems with babies and other family members. Sometimes, they were seemingly passive recipients, while others were in a more interactive role, for example, in dialogue with other women and different healthcare providers.
While many images came from rural contexts, one photo showed a female community health worker visiting an adolescent mother and her child in a low-income urban settlement in India 3, arguably portraying the trust that can enable positive patient–provider relations. Urban contexts provide different challenges for community-based work, given that populations are more mobile, settlements often illegal, and programmes non-existent in contrast to rural areas 1112.
Figure 3 Community health worker and stories of the urban poor.
Photo credit: Bhargav Shandilya. Photo location: Bangalore, India.
While demonstrating the importance of women as close-to-community providers, very few highlighted the working conditions of these frontline health workers. Women systematically are paid less than their male counterparts in the health workforce 1314, at times receive unequal non-pecuniary benefits 15 or work in contexts that are highly constrained and disempowering 16]. A photo of the Employment Equity Policy Guiding the Appointment of Staff in Health Facilities in South Africa quite explicitly raised concerns about employment terms. Only one photo showed an immunization officer and health committee member who were nursing mothers themselves. Strikingly, there were very few photos of women as facility-based health professionals, and only one photographer documented a woman in a managerial role: a nursing officer in Uganda resting on her motorcycle, self-assured while straddling a motorcycle typically associated with men. These images starkly reflect the multiple ways that hierarchy and gender intersect to stratify the health sector in inequitable ways 1718.
Where are the men in gender and health systems?
Men were also highlighted in gender transformative ways by the photo competition. Male peer educators provided HIV testing and counselling to couples from nomadic communities in rural Kenya (Figure 4). Another image showed a group of rural Indian men in a circle happily chatting, some leaning forward to engage, others listening, all seemingly relaxed. The photo captures them brainstorming on spousal communication and family planning decision-making. Another photo is of a young man in the library in Ghana attentively and quietly engrossed in a journal of obstetric nursing. From Cambodia, we received images of male nurses being trained alongside female nurses, caring for children in a Cambodian hospital that prides itself in promoting a more equitable work environment. And in the US, male and female public health students collaboratively engaged in a campaign to raise awareness of gender-based violence. These examples highlight the important role men play in working alongside women, engaging with women’s health concerns and advocating for gender equality. Given the social vulnerability of men to chronic diseases and injuries, attention to men’s gendered risks underpinning these imbalances is also critical 19.
Figure 4 Reaching the hard to reach, nomadic, young and old with HIV testing services in Kenya. Photo credit: LVCT Health. Photo location: Eremit Village, Kajiado, Kenya.
While these were good examples of the ways that men are supporting their communities and societies to combat ill health, there were very few submissions documenting the role of men as health providers, managers or politicians engaging in gender issues as a way of transforming health systems. Fewer still documented the role of men as frontline and close-to-community providers of healthcare. One image from Mozambique starkly depicted a male provider sitting at a desk out in the open facing a multitude of women waiting to see him. Given the influence of men in health systems – particularly the politics, policy and decision-making processes from the global to the household level – the relative absence of men photographed in these roles is interesting. This perhaps reflects the ways in which gender is so often equated with women but also how the visible face of frontline health and community systems is often female.
What issues arise being close to communities?
Many photos pictured women in active roles farming, buying, producing and processing food stuffs. For example, women in Nigeria were pictured processing forage powder using local stub to fry soya beans, groundnut and millet for weaning children. While these images were not immediately obvious “health systems” images to the staff judging the competition, they demonstrated the importance of nutrition to health in the minds of photographers and are a reminder of the importance of inter-sectoral action for health.For some of the women pictured, the livelihoods they relied on entailed extremely arduous working conditions and serious occupational risks. Female crab collectors from the Sundarbans, who were predominantly from households where men had out-migrated for formal sector employment, stood deep in mud and braved tiger attacks. Fisher women from the same community were pictured thigh high in water risking skin diseases and reproductive tract infections. One image was of women who journey approximately 10 hours from Cameroon to Nigeria carrying heavy loads of corn by foot to get it milled and then return to Cameroon with the flour. While all the photos of close-to-community health provision focussed on maternal and child health needs, these photos highlight the ways in which gender roles shape livelihoods and food production, which in turn shape health experiences and outcomes. Close-to-community health providers are embedded in communities and may therefore be strategically placed to understand intra-household gender and power dynamics and how social determinants, such as poverty and food security, shape health and well-being. However, the opportunities to develop critical awareness and to translate this knowledge into health system and multi-sectoral action are poorly understood 20
Ethical considerations related to power
The question of who has the right to take and display images, under what contexts and for what purpose permeated the photo competition. Although we disseminated guidelines on the ethics of informed consent for photography, only one photographer made reference to a code of conduct with regard to use of images 21]. Most photographers reported verbal consent or written consent where possible. Nonetheless, several photo submissions did not detail consent or reported consent that was more casual in manner: photographers pointing at the camera and seeking consent non-verbally. However, this fails to distinguish between seeking consent for taking a photo, whether for personal memories or for professional imperatives, and seeking consent for disseminating the image publicly, whether for profit or non-profit motives (in this case, there were no direct financial gains from the competition). We cannot guarantee that all the photos submitted to the competition followed the recommended ethical principles with regard to consent. However, in the case of the photography competition, only photos that more clearly outlined consent for dissemination were considered for honourable mention and further publicity. Further follow-up with photographers was also undertaken before disseminating the images more broadly.Ethical principles in photography and use of images go beyond issues of consent 3, 22, 23]. They span issues of justice, autonomy, non-maleficence, beneficence and fidelity. Are we representing subjects respectfully, in ways that do not further marginalize, stigmatize or exploit them personally? Do the images raise questions about health workers, their health system realities and broader public health priorities to support constructive social change? It was striking that several photographs submitted did present traditional images of women as passive beneficiaries of maternal and child health services. Certain aspects of community health provision may be so normalized that they remain invisible. How does this influence policy and programme considerations for close-to-community providers? When reviewing lay health worker policy in South Africa, for example, policymakers failed to see the gendered origins of the working conditions that were acknowledged to be problematic 24].Who else benefits from the images being shared and in what ways? It is striking how photo credits are often for the photographer alone, without acknowledgement of the person or people photographed or the organization sponsoring the photographer. This may be to protect individual identities, but photos can be even more personal than research findings because they can be more irrefutably identifiable or contextually revealing. Feminist research ethics interrogate who has the right to be an author representing the realities of others and how; but how do we apply such principles to photography and photography competitions?Most of the photos submitted were by photographers who remained in control of shaping what was included in the images. The photos highlighted, while positive, do not necessarily express the active voice and perspective of close-to-community service providers themselves – their views, struggles and dilemmas. Large-scale participatory projects, such as the World Bank’s “Voices of the Poor”, even with their limitations, demonstrate that policymakers can be moved by participatory methods 25]. Participatory approaches are increasingly recognized as a vital part of health systems research 26]. For example, photovoice offers important opportunities for community members and health workers to contextualize photos in relation to the individual and institutional realities that they experience.But there are tensions within participatory approaches, and politics and power play out in multiple ways. The two photovoice submissions were not initially selected by the judges as they were not as well composed as those submitted by professional photographers. Without understanding the transformative process behind those images, photovoice submissions can be dismissed as being of poor quality and can fail to present a compelling argument in an increasingly crowded communications environment characterized by large marketing budgets, high-specification technology and vastly more professional outputs. Within this environment, it may be difficult for the messages conveyed through participatory photography projects to gain traction.In response to this, some researchers have explored how partnerships between creative professionals and poor and marginalized groups can generate more compelling products for a general audience with no particular interest in alleviating poverty. For example, the Pathways of Women’s Empowerment Consortium has reimagined old fairy tales in Egypt and pop music in Ghana in order to challenge established narratives about women 27]. This kind of storytelling is a powerful medium for changing critical consciousness. Can such avenues also be explored to celebrate the heroes that hold up community health systems the world over? Close-to-community providers are critical foundations for communities and health systems but rarely are given opportunity to decide on the images that portray them or their perspectives.Finally, while we purposefully framed the terms of the competition to encourage lay and amateur photographers to get involved, particularly supporting further creativity and visibility among health systems researchers, this had the unintended consequence of further marginalizing some professional photographers. In a world of skewed financial resources, some professional photographers struggling to maintain their livelihoods found the non-financial terms of our photo competition an affront to their expertise, skills and profession 28]. This raises questions about the nature of photography competitions and participation in general, something which development organizations have been criticized for in the past. Photography competitions are sometimes used as a way to solicit unpaid work. As a result, they can create false incentives among the photographers who enter and can be unfair for those who look to make their living from photography.One response to our photo competition suggested that if the aim of the competition is to generate discussion, provide a voice to the otherwise voiceless or help researchers better communicate their research, then not offering a monetary prize or financial incentive may not be problematic. However, if the aim of the competition is to obtain professional photographs to use within publicity campaigns, then prizes should be offered which recognize the costs of producing the images and help contribute to the livelihood of the photographer 29]. Based on this feedback, we agreed to not use the photos for publicity purposes beyond the confines of the photography competition. Greater transparency is needed within photography competitions regarding the aim and purpose of the competition, and participants should be made aware of what the intended use of the photographs is. This would help to ensure that competitions do not add to the exploitation and maltreatment of photographers.
Conclusion
Photos can capture nuances or startle us and communicate issues powerfully and symbolically in ways that are sometimes more enticing, convincing and memorable than in tomes of written evidence that may or may not be read or remembered. Writing on the importance of creative communication in the uptake of research on women’s empowerment, Lewin 30: 223] has argued that, “good empirical research; intellectual work and compelling arguments are not enough to provoke change. People need to see alternative realities; utopian visioning is a political project. We need to see the world presented in different ways – our emotional and visceral responses are very important in shaping how we think, and more importantly, how we feel”. This is particularly important in relation to gender and health systems where the generation of political will to develop and act on an evidence base is necessary. It is also particularly relevant to close-to-community providers, who are too often treated as “resources for human health” rather than as people with needs and rights themselves 17, 24].The health system research field has begun to wake up to the potential of online social media in research communication (as exemplified by the recent Social Media awards at the 2014 Global Symposium on Health Systems Research). Looking to the future, the role of social media – such as Instagram and snap chat – which encourages the rapid exchange of photos and video images in unmediated ways will increase rapidly 31]. Key opportunities of this include activism, challenging stereotypes and breaking news of abuses. At the same time, issues of consent, agency and justice are of critical importance to ensure that photos are not taken out of context and do not objectify or disempower health workers and other health system actors who are at times on the margins of health systems. This is a fast changing world posing challenges to health systems researchers to stay with the curve, let alone get ahead of it to shape future trends. The opportunities and challenges of evolving media and mobile technologies for democratizing photography to highlight gender, human resources for health and health systems in transformative ways need further attention, analysis and action. Endnotes 1RESYST: Resilient and Responsive Health Systems, REBUILD Consortium, Future Health Systems: Innovations for Equity
tion id=”Declarations” class=”Section1 RenderAsSection1″ data-test=”declarations-section”>Declarations Acknowledgements
The authors would like to acknowledge everyone who took part in the photo competition. We would also like to acknowledge the Global Symposium on Health Systems Research for allowing us to showcase the photos during the conference in Cape Town. All authors are members of Research in Gender and Ethics (RinGs): Building Stronger Health Systems, funded by the UK Department for International Development (DFID) for the benefit of low and middle income countries. The views expressed are not necessarily those of DFID. We would also like to thank Future Health Systems (FHS), ReBUILD and RESYST for contributing to photo printing costs so that the photos could be displayed at the symposium. In addition we would like to thank FHS, RESYST, and REACHOUT for supporting open access publication costs. Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsAG made substantial contributions to the conception and drafting of the manuscript; ST and KH have been involved in drafting the manuscript or revising it critically for important intellectual content; RM and SM have been involved in revising the manuscript critically for important intellectual content. All authors read and approved the final manuscript.
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The life of a meeting report writer is a lonely one. It is easy to get caught up in the energy and excitement of an issue when surrounded by fascinating and challenging speakers. But once everyone has flown home and you are wading through 50 pages of meeting notes, trying to decipher acronyms and cryptic quotes you sometimes feel like you are drowning in a mass of information you will never make legible to those who didn’t have the privilege of attending. So to give myself a bit of impetus and help order my thoughts I have come up with a list of what I consider the top 5 take home messages from the recent Pathways of Women’s Empowerment meeting.
To add to the complexity of synthesising simple messages, the meeting made it clear that there is no single feminist nor a single development actor. Those involved in this field inhabit very different worlds, subject positions, politics, and positionalities. When we sit outside the places that people live and look in on them, we can fail to make sense of, listen to, and resonate with women’s lives. Those caveats aside, here are the messages:
1. That there is a gulf between policy advocates engaged in post-2015 agenda setting and the fears, dreams and demands of many women organising in disparate settings. The skills required to track and influence advocacy at the global level are very technical and a particular cadre of feminists occupies this space doing vital and necessary work. But somehow, post-Beijing, the parallel structures which enable these staff to adequately network with women at the grass roots have been lost. (Re)building this dynamic and organic network of links and entry-points for dialogue is a key priority.
2. There is a translational issue. Women’s movements have been just as good as any other advocacy group in developing clear messages for policy. However, what is understood by the term ‘women’s empowerment’ differs between large development institutions and social movements struggling for justice. All too often empowerment is instrumentalised – as exemplified by catchphrases like ‘gender equality is smart economics’. The reductionism and sloganeering of the development sector sometimes strips the politics out of the work.
3. Feminist networks and monitoring, learning and evaluation experts need to work together. Participants at the meeting decried the difficulty of generating indicators and systems which would allow them to trace the impact of strategies like collective organising and consciousness raising. They also rightly pushed back against a value for money and results agenda which inadequately traces the types of change in women’s lives which women believe are important. More could be done to foster partnerships between feminist activists and progressive evaluation experts who are trialling methodologies such as process tracing and realist evaluation to strengthen this area of work.
4. Research has failed to adequately deal with the implications of global capitalism for women’s empowerment. The global financial crisis has had a very debilitating effect on global policy spaces. At first people with a progressive slant to their politics thought that it would highlight the failure of capitalism and provide an opportunity to create a new world. But the opposite has happened and neo-patriarchialism has been enforced. Moving forward this needs to be central to research agendas.
5.Forging new alliances and intersectionality will be central to the future of feminist activism. The importance of partnering and working together with men, sexual rights activists, the creative industries, workers movements, revolutionaries and legal and religious scholars with an interest in social justice all came through strongly in the meeting. As did the idea that women have complex identities which encompass a number of interests and issues beyond women’s rights. There is a need to be strategic about these alliances and understand that there will be instances where interests do not necessarily collide. Furthermore, women’s movements need to guard against instrumentalising others in the push for women’s empowerment.
I hope that this blog gives a flavor of some of the issues that we discussed. I am relying on my co-author Jenny Edwards to add a bit of oomph to the text I have come up with. And we are planning to bring together some of the multi-media content from the meeting which will make it all the more engaging. Join the Pathways of Women’s Empowerment mailing list to get a notification of when the report and the multi-media contents go live and watch this space for details of how to learn more…
Kate Hawkins is a member of the Sexuality and Development Programme International Advisory Group and the Director of Pamoja Communications.
All over the world women’s rights activists, gender experts, donors, government representatives, and UN staffers are gearing up for this year’s Commission on the Status of Women (CSW) which will take place from the 10 to 21 March in New York. This year’s theme is ‘Challenges and achievements in the implementation of the Millennium Development Goals for women and girls‘: A timely topic that suggests there is still a little time for some reflection and learning, in the midst of the clamour of advocacy to shape the post-2015 agenda.
Where we’ve gone wrong Whilst there are a multiplicity of opinions about how the MDGs may have supported or undermined the push for gender equality, some central strands of argument stand out:
They failed to build on the progressive thinking and consensus building that occurred in order to construct the Convention on the Elimination of all Forms of Discrimination against Women (CEDAW), the Programme of Action of the International Conference on Population and Development (ICPD) 1994 and the Beijing Platform for Action at the Fourth World Conference on Women, 1995. This progress took us from the abstract instrumentalism of ‘women in development’ to seeing ‘gender and development’ as social relations of power and (in/) justice.
At their creation the MDGs did not include a goal or target that explicitly dealt with sexual and reproductive health and rights, but mainly saw women in their stereotypical role as mothers and carers of children. Whilst the World Summit in 2005 recommended the integration of the goals from the ICPD into the MDG monitoring framework their initial omission probably set back action on maternal health over the longer term and meant some issues like sexual rights and access to safe abortion were side-lined.
Within the Goals women were framed as individual agents of economic growth and development, hence the focus on improving access to education, literacy rates and employment. Yet, they did not tackle the potentially negative aspects of fiscal policy, the discrimination and abuse that can be experienced within waged work, nor did they tackle the incredible, soul-sapping, back-breaking burden of unpaid care which women throughout the world shoulder disproportionately.
The framework said nothing about how the world should tackle underlying systems which shape and perpetuate intersecting inequalities in different settings. How human rights might be part of the solution and how we go beyond improving average outcomes to a focus on the most neglected and marginalised amongst us. They say little about power and its workings or paint a picture of a world which is transformed through a new approach to gender.
The MDGs fail to acknowledge the importance of women’s participation (beyond in parliaments), their social movements and their organisations in furthering gender equality and broader social change, let alone what role men might play in the struggle for gender equality.
Working together for change Calls for a stand-alone goal and the integration of gender throughout the post-2015 consensus are growing in strength. Many are thinking about how these might be operationalised. As part of this process colleagues from IDS will be holding a roundtable at the CSW which will explore the steps we need to take to create strong and sustainable alliances to influence global policy processes, to challenge the myths and expose the reality of gender inequality worldwide. The meeting is part of the Gender, Power and Sexuality Programme, funded by Sida, and is a follow-up event to a multi-stakeholder roundtable held by IDS and SDC at CSW in 2013 on the need to put gender at the heart of the post 2015 agenda. It promises to be a lively and cutting-edge event which will highlight thinking which doesn’t normally find expression in mainstream CSW debates.
Join us in New York – or online Attend and hear how patriarchy and its relation to intersecting forms of oppression – linked to sexuality, (dis)ability, race, class, ethnicity and nationality – hinder progress on social justice. Debate with panellists what role men’s movements have in gender equality; particularly in tackling gender-based violence and equalising the distribution of care responsibilities. Explore how attitudes, behaviours, and stereotypes about women – both conscious and unconscious – prevent wider social movements from taking gender equality seriously.
This is an event which responds to a desire for change and new ways of looking at the world and how we come together, in partnership and dialogue to build something better. In the words of my colleague Jerker Edstrom,
’We need to think outside the box, to link across social movements to highlight these issues. Many of us recognise the underlying structures of constraint which hold us back, but there is a need to create alliances to make changes in policy and practice which have real resonance.’
Event details Speakers: Hazel Reeves (writer and women’s rights activist), Gary Barker (Promundo), Jerker Edström (IDS), Zahrah Nesbitt-Ahmed (IDS) and Mariz Tadros (IDS) Chair: Andrea Cornwall (University of Sussex) Date: Wednesday 12 March, 12:30 pm Venue: The Guild Hall of the Armenian Convention Center, 630 2nd Ave (at 35th Street), NY
He Xiao Pei, a long-time partner and collaborator of the Sexuality and Development Programme and Pathways of Women’s Empowerment, recently launched a new documentary. I was lucky to attend a screening of the film at the University of Sussex just before Christmas. The film, Our Marriage, is an exploration of the lives of four lesbians who decided to marry gay men in order to secretly pursue their relationships with their girlfriends and at the same time fulfil their families’ deep-seated desire that they get married. The sense of respect and responsibility that the marriage partners feel towards their parents, and the avoidance of social ridicule and tricky questions about their child’s sexuality, also play a large role in their decision to stage elaborate and glamorous sham ceremonies. The film has already been shown in Thailand to positive reviews.
Heteronormativity in China In China, as one of the women in the documentary explained, nobody is allowed to be single. Whilst a burgeoning lesbian social scene is becoming more visible in large cities, heteronormative attitudes force people, heterosexual and homosexual alike, into marriages which they would rather avoid. Marriage can provide social acceptance, but it also gives you certain economic benefits such as access to social housing. Whilst homosexuality is not illegal in China there are no plans to introduce same sex marriage. Activists like He have argued against campaigns for same sex marriage suggesting that the institution of marriage itself should be challenged as it supports patriarchal norms and is detrimental to all people, whether they are gay, straight or bisexual.
Searching for a spouse The documentary is another reminder of the links between information and communication technologies and sexuality in low- and middle-income countries. Information about couples interested in a contract marriage and hook ups can be made online through QQ and other web platforms. These sites have also attracted heterosexuals looking for a contract marriage to reduce family pressure.
Getting wed The film approaches the subject matter with a large dose of humour. In fact the documentary gently satirises and ridicules the institution of marriage itself. Usually plainly dressed women are shown in dramatic wedding dresses crooning love songs to their ‘fiancés’ in scenes that prompt giggles from the audiences. Stretch limos transport family members to huge, elaborate receptions. Displays of wealth and social networks are definitely a big part of saving face. But beneath the veneer of ‘respectability’ none of these marriages are real, and no legal marriage documents are ever signed.
That’s not to say that the couples involved don’t have a clear idea of the arrangement that they are entering into. Documents are drawn up by the marriage partners beforehand specifying that they will have no interference in each other’s finances and that they waive the right to inheritance, they agree to tell each other their whereabouts (as few couples actually live together after marriage), they discuss how they will raise potential children and where they would live, finally, there is an agreement that in the case of major illness the ‘marriage’ will be dissolved. No ‘till death us do part’ for these couples! But it is not like you can have a contract marriage with just anyone, being friends is important. One women’s potential husband asked her to have surgery to ‘fix’ her face so she would look pretty in front of his family and friends. Unsurprisingly his generous offer was rejected.
Accessing the film To protect the identities of the lesbians in the film the documentary is not available online and it hasn’t been shown in China for the same reason. But the women involved felt strongly that they wanted their story to be told. Some feminists told them that they are cheats and liars for entering into contract marriages. That sham marriages are a compromise and that they should challenge convention by ‘coming out’. But these women wanted to document the difficult reality that they are facing. In many ways the documentary is a love story, a story of the love the women feel for their families and the lengths that they will go to in order to protect them. It deserves a wider airing. If you are interested in showing the film please contact He Xiao Pei directly on infopinkspace@gmail.com.
