Richard Smith: What has feminism done for global health?

Richard SmithThe Lancet, the leading journal for global health, has mentioned feminism only twice in its 189 years . The BMJ hasn’t mentioned it at all. So that looks like some evidence that feminism has had no impact on global health, but all three speakers at a meeting at the London School of Hygiene and Tropical Medicine this week strongly disagreed.

(Ironically this paragraph illustrates the superiority of women over men. Richard Horton, editor of the Lancet and a man, told us that the Lancet had mentioned feminism only twice, and Tony Delamothe, deputy editor of the BMJ and another man, told me that the BMJ had no entries. I, a third man, didn’t check, but Jane Smith, another deputy editor of the BMJ and a woman, did. She found that the BMJ has had 102 mentions of “feminism” and 302 mentions of “feminist” and the Lancet has 23 mentions mentions of “feminism” but none of “feminist.” Thank God for women.)

One reason that the journals might not have mentioned it is because “feminism” is a taboo word within academic medicine, said Richard Horton, editor of the Lancet. Lori Heise, one of the speakers and a senior lecturer at the London School, said how she had to think carefully before “coming out” as a feminist.

Feminism can mean many things, said Andrea Cornwall from Sussex University, but all definitions coalesce around inequalities and inequities. It is a political practice concerned with reducing those inequalities and inequities—and such a programme is central to global health.

Cornwall quoted the famous book Our Bodies, Ourselves as one of the best examples of how feminism has been important within global health. Described by the New York Times as a “feminist classic,” Our Bodies, Ourselves was published in 1971 and grew out of a pamphlet Women and Their Bodies written by 12 Boston feminists. The booklet sold 250 000 copies without advertising, and the book is now in its 9th edition with 26 foreign editions. The book had a specific political purpose and was the first to insist that health is not a matter just for experts but for women—and men—themselves. Now a commonplace idea it was a radical idea in 1970.

One of the great feminist battles has been the fight to get rid of unsafe abortion. The battle was won in Britain in 1967 but continues in much of the world—and is in constant danger of being rolled back, not least in the United States. Feminists have also led on the right for women to control their fertility and on humanising childbirth. Cornwall said that despite some female politicians—like Sarah Palin—having reactionary views the increase in the proportion of women in legislatures is associated with progressive reproductive legislation.

Heise made the case for feminism’s importance in global health by telling three stories. The first concerned a WHO report on violence and health from 1993 that in its first iteration said nothing about violence against women “in the personal sphere.” Feminists, including Heise herself, convinced WHO of the importance of domestic violence and not only ensured that it was included in the report but also changed the paradigm for thinking about violence and health.

Her second story was about the movement for population growth in the 1950s and 60s. Although driven by concern for the environment, the movement had a “tinge of eugenics” and led to unacceptable practices like forced sterilisation. Feminists broadened the debate by pointing out that overconsumption was as important as overpopulation in damaging the environment, and they made clear that flooding the world with contraceptives would not on its own reduce population growth. It was essential to address issues like empowering women and educating girls. Ultimately concern about population growth was replaced by concern for human rights and sexual health, a victory for feminists.

(As I type this, I’m listening to Michael Bublé sing “Chicks were born to give you fever, be it Fahrenheit or Centigrade,” reminding me that feminism has some way to go.)

A third achievement of feminism described by Heise has been the inclusion of women in clinical trials. In the 80s almost all trials included only men—because triallists, particularly those from pharmaceutical companies, were scared of the liability implications of including any women who could possibly become pregnant. Because of feminist pressure this has now changed, but, said Heise, pregnant women are the “real dispossessed.” Prescribing in pregnancy is rarely based on good evidence. Somebody in the audience asked how this might be changed, and Heise answered that it needed legislation to require the inclusion of pregnant women in trials and a fund to avoid individual companies having to pay out for problems.

Despite the desire to include women in clinical trials, one of the recurrent themes of the meeting was a distaste for randomised trials. Nobody put it this way, but I was left with the feeling that randomised trials are male inventions—ignoring  subtlety and nuance and reducing people to statistical objects. All the speakers made clear that they were not against randomised trials, but we were left with the impression—almost certainly correct—that the world would be a better place with fewer trials and greater use of other research methods, particularly participatory research,

Feminism clearly has made an important contribution to global health. (And if the BMJ posts this blog there will be several more mentions of feminism and feminist in the journal.)

Competing interest: RS is a man but likes to think his feminine side is strong. His wife, a woman, thinks he’s wholly mistaken. RS was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.