Abstract
Introduction
This book is not a legal text per se, but it addresses issues of great importance for medico-legal academics; power, politics, exploitation and neglect – and the legal frameworks which shape and enable the operation thereof. It draws from interviews conducted by the author, prioritising ‘narrative over academic citations and debates’ (p. 272). This gives us a rich and unique insight into a complex topic. Should the academic reader wish to supplement this book with more traditional sources, the ‘Sources’ section at the end of the book provides a solid starting point (p. 272).
Sick of It
Harman starts by unpacking the relationship between global politics and women’s health, debunking the ‘total misconception’ that women’s health ‘gets little attention in the world or political leaders don’t really care about it’ (p. 5). Rather she argues women’s health does not get attention for the right reasons. Women’s health is rarely platformed on the global political stage ‘for the purposes of improving women’s health’ (p. 4); instead, it is used and abused as political currency, for political ends. In this process, women’s ‘cheaper, or sometimes free, labour and expertise’ are exploited within both the health and campaigning systems (pp. 4–5). This creates space for a more nuanced understanding of what is happening. This is important; without understanding the true nature of a problem, we cannot hope to address it.
The body of the book is organised into three parts. There is not space here to detail all of the wide-ranging issues raised throughout. Instead, my aim is to pull out those which struck me as particularly pertinent, interesting or contentious from a medico-legal perspective.
Part 1: Saving Mothers
This section sets out the potency of women’s health as a political currency and the exploitation of this in ways which often fail to serve women’s actual health needs (or only serves those needs which are deemed palatable to voters). Harman illustrates how the politicisation of women’s health allows external forces to create harmful binaries: un/acceptable health interventions, un/worthy patients, un/fundable concerns.
Chapter 2, ‘The Aid Boom and Saving Mothers’, demonstrates how the political nature of the global women’s health agenda has shored up the pervasive problem that women are only seen to matter in relation to their (potential) reproductive capacity, rather than as individuals in their own right (p. 30). The need for political palatability sees many lifesaving issues/initiatives (e.g. abortion and contraception) side-lined, in favour of an agenda which squarely focussed on ‘saving mothers’ rather than improving overall women’s health. To attract funding and support, women’s health efforts must provide useful political currency. This explains the tunnel-vision emphasis on mothers: ‘saving mothers appeals to governments in the UN, voters, aid givers and society at large because saving mothers equals saving babies’ (p. 37).
Chapter 3 focusses on the role of hard power, particularly the ‘global gag rule’, in shaping and constraining global women’s health efforts. This chapter reminds us that the world is a deeply interconnected place, where the whims of one ‘powerful’ nation can impact others in myriad (harmful) ways. Reading this book in the weeks after Trump was re-elected, this feels particularly prescient.
Importantly, Harman also demonstrates that it is not just the letter of the law that restricts access to health care; fear and confusion among healthcare providers regarding the exact parameters of law can further broaden the net of restrictions. Thus, legal literacy is important for activists in this area. Harman explores how Reproductive Justice activists use detailed knowledge of the law as a tool of resistance – educating healthcare professionals about the true nature of the restrictions, and keeping policy-makers and governments in check to prevent unnecessary or unlawful expansion of abortion restrictions (p. 55).
The part finishes with a timely and moving chapter about attacks on (access to) maternity care as a weapon of conflict; be that through ‘a slow burn of depletion’ (p. 77) (Palestine) or the direct ‘bombing of maternity hospital’ (p. 79) (Ukraine). The ongoing escalation of violence in Palestine in the time since this book was published reminds us that these two forms of attack are not mutually exclusive. The chapter outlines how women’s health is politicised and rendered symbolic in times of conflict (p. 83) – removing the focus on the actual on-the-ground needs and experiences of the women impacted.
Part 2: Exploiting Women
This section concentrates on the ways that women (as both recipients of aid and as healthcare workers) are exploited in the health and aid sectors.
Chapter 5 explores the problematic ways in which the international aid sector exploits the trauma of vulnerable people accessing healthcare services during humanitarian crises. Here, Harman exposes the less obvious ways in which legal systems can enable and perpetuate harm – for example, outlining the way that copyright rules intersect with unethical and exploitative practices regarding taking (identifiable) images of those accessing humanitarian health services. She also raises the important question of what it means to ‘give informed consent in a humanitarian crisis’ (p. 96). This speaks to a growing body of scholarship seeking to critically interrogate how the concept of consent is understood across law. 1
This issue of informed consent is then considered in the specific context of children, and it is here that my first point of substantive critique arises. Harman states ‘there is a reason why children cannot give informed consent’ (p. 97). Speaking to the UK context, this statement is an oversimplification of the legal position regarding children and consent. A child who is found to be Gillick competent can give informed consent to medical treatment regardless of their age. 2 Setting aside the legal critique, I have a more general concern with this very binary assertion and the role it can play in removing agency and citizenship from children.
Chapter 6 provides a harrowing account of the prevalence sexual exploitation, harassment, and abuse in humanitarian crises; powerfully illustrated using real life experiences. Importantly, the chapter deconstructs and rejects the common claim that such abuse occurs due to ‘a few bad apples’ (p. 106), illustrating that such abuse is instead enabled by institutions which are more focused on protecting themselves and their reputations than the victims of abuse (p. 112).
Chapter 7 explores the harm and violence that healthcare workers face at work, and the gendered nature thereof; noting, for example, that ‘nurses are subjected to more violence than any other type of health worker’ (p. 122). Recognising the violence directed towards those performing substantially gendered care labour is important. Those delivering care operate within the same hierarchal, patriarchal and exploitative systems as those receiving that care; and are harmed by the same pervasive problems which undermine women’s health.
Harman is undoubtedly correct that healthcare institutions need to do more to protect their workers from (gendered) violence. However, in seeking justice for one group, it is vital not to accidentally push inequality onto others. Describing an incident in which an NHS worker was injured by a patient, Harman writes,
The attacker was of ‘no fixed address’ and was in hospital following a drug overdose. It does not take too much to work out that this man was potentially a homeless drug addict, and therefore fitted a certain risk category of someone who may become agitated or violent. He could have been flagged as a risk and proper measures taken to protect the health worker. (p. 127)
Her framing sits uneasily with me. Of course, healthcare professionals deserve safety. That ‘violence is a normalised part of working in the healthcare system’ is damning and must be addressed as a priority (p. 133). However, advocating for a form of profiling that frames certain vulnerable populations as primarily a risk (to others) to be managed – rather than as people who are in real need of care and support – does not feel like an appropriately thoughtful or nuanced response to this complex situation. It also seems at odds with Harman’s otherwise very considered approach.
Chapter 8 explores the cyclical and systemic impact of burn out; when healthcare workers are overburdened, underappreciated, and inadequately protected, many burn out, and may quit. The more people quit, the more those left behind have to do, the more burnt out they get. It is also a gendered problem; not only because the majority of healthcare workers are women but also because feminised care labour is so often undervalued and overlooked. 3 Women face a double burden; they both bear the brunt of burn out and are the ones who are called upon to fill the resultant gaps, in even more exploitative conditions ‘as volunteers, home-based carers, community health workers to semi-professional health workers’ (p. 150). Chapter 9 dedicates its attention to these women, who experience the sharpest end of exploitative political decisions about what their indispensable labour ( ‘no health policy in the world would work without them’ (p. 153)) is worth. In a world where donors manage to find funds for ‘expensive tech’, Harman reminds us that ‘not paying community health workers and carers’ is unquestionably a ‘political choice’ (p. 165).
Part 3: SOS! (Same Old Solutions)
In the final section, Harman explains why reaching for the ‘Same Old Solutions’ will fail to actually bring about improvements in women’s health.
One of the most common responses to the concerns laid out in this book is to argue for more female leadership in health (Chapter 10). Yet those women seeking such leadership roles are not free from the systemic, patriarchal constraints set out in the preceding chapters of this book. Too often, ‘extremely qualified women’ are passed over in favour of ‘the most qualified male candidate’ (p. 185). Where the system within which global health operates is fundamentally flawed, simply advocating for more female leadership cannot operate as a panacea. Chapter 11 explores how similar issues arise when one attempts to address global gender health inequalities by calling upon gender experts. These experts are, like so many other women in this ecosystem, overworked and undervalued.
In the final chapter, Harman explores the power and use of data in the global health space. Data is used to shape agendas; alongside its potentially transformative impact lies a darker power – the power to ‘exclude issues, priorities and people’ (p. 211). Harman’s thoughtful critique of data, which recognises that ‘data, like any form of power is never without bias’ is very welcome (p. 211), and has ever increasing relevance that reaches across a range of health contexts. As part of her nuanced critique of data’s role in addressing health inequality, I was really pleased to see important recognition afforded to the unique challenges faced by non-binary and gender diverse people – who are too often ignored in these conversations. Where gendered data is collected, this generally only provides for categorisation within the male/female binary, meaning that the collection of data ‘can completely erase people’s existence’, thus erasing ‘health needs that may be specific to a part of their identity’ – meaning these needs ‘go completely unseen’ (p. 214).
Ultimately, Harman concludes, it doesn’t matter whether the person raising an issue is a ‘leader’ or an ‘expert’, or whether we have the right amount of data; ‘in the end, whether an issue is heard and acted upon depends on whether someone will hear it’ (p. 202). One cannot solve the epistemic injustice faced by women simply by having more women speak; 4 rather we need to tackle the systemic barriers which result in women not being heard/taken seriously when they speak. In the Epilogue, Harman outlines a range of ‘productive’ (p. 248) steps that everyone can take to help drive towards the goal of changing the (broken) system and improving women’s health globally.
Broader reflections
Before concluding, I offer three further reflections which speak to the book as a whole.
First, I applaud Harman’s decision to integrate stories and experiences from the United Kingdom as well as from abroad when outlining the way that women and female healthcare workers are harmed by the current system. This prevents the reader from being able to ‘other’ the issues presented in this book, or to dismiss them as things that happen elsewhere. It reminds us that improving women’s health, and the conditions within which women deliver healthcare, represents an urgent task for all nations.
Second, I was struck by how many of the stories in this book involved situations where supposedly protective legal frameworks were in place, but yet utterly failed to achieve their intended goals (e.g. to safeguard against sexual exploitation in humanitarian settings (Chapter 6) or to respond to violence against healthcare workers in the NHS (Chapter 8)). This serves as an important reminder of the need to look beyond the black letter of laws and regulations, to examine their actual operation.
Finally, this book speaks incredibly clearly to the issue and impact of power: who has it, how they wield it, and to what end? We see this in the decision about which initiatives get funded and which don’t (Chapters 2 and 3), in who gets ignored and who gets protected when evidence of institutional sexual harm comes to light (Chapter 6), in the nature of people’s journeys to physically access healthcare spaces (Chapter 4) and whose expertise gets listened to (Chapter 11). For legal scholars, power and the operation thereof offer provides a key lens through which to parse and critique health(care) systems, institutions and problems.
Conclusion
As I write this review there are acute reproductive justice crises in Palestine 5 and Sudan. 6 Women in Afghanistan have been banned from speaking outside their homes, 7 and Iraq has proposed lowering the age of consent for girls to merely 9 years old. 8 Donald Trump has just been elected as the President for a second term, 9 and right-wing populism in Europe is rising. 10 Against this context, Harman’s message is more urgent and salient than ever.
The book does an impressive job of remaining accessible, while maintaining a commitment to addressing the nuance and complexity of the issues it addresses. In the introduction, Harman reminds us that ‘women’s bodies have always been a site of contested politics’ (p. 3), and throughout the book, she powerfully illustrates the devastating and very real consequences of this. The books core strength lies in the fact that it so vividly brings to life the lived experience of law, policy, power and politics, and the deeply gendered impacts thereof.
