Sick of It: The Global Fight for Women’s Health by Sophie Harman – the war on wellbeing

The new Labour government is busy looking for ways to depart from the Conservatives’ legacy. One target may well be the 2022 women’s health strategy for England, an underfunded package of insufficient medical offerings that sidestepped important questions about inclusivity and narrowly constrained women’s health to conditions affecting the uterus, ovaries and breasts. As if women don’t have other body parts that go wrong. It is tempting to see the strategy as a smokescreen for how badly the Tories have let women down: widening gender pay disparities, leaving half a million people stuck on gynaecology waiting lists, prompting fear about maternity failings, burdening women with childcare constraints and excluding them from political decision-making.

In Sick of It, Sophie Harman expertly shows that failings at home are mirrored and magnified across the globe. For all the talk about the importance of women’s health, “no country has broken a trade deal, a special relationship or sanctioned countries” over the wellbeing of women and girls. A professor of international politics specialising in global health, Harman is perfectly placed to explain the forces that shape women’s health, from Kenya and Sierra Leone to Washington and Geneva. Harman highlights the misapprehension that women’s health is a “neutral scientific space free from politics”, where leaders follow the data and deliver what works. Instead, women’s health is often used as mere “diplomatic branding”. Sick of It exposes how women are exploited as recipients of aid and medical treatment, as healthcare workers and unpaid carers, and as female leaders outnumbered by men.

Women’s health is a currency of power and influence. In Rwanda, over the last 25 years, Harman describes how Kagame’s government publicly prioritised maternal outcomes to “healthwash” atrocities of oppression and killing. Success stories such as an 85% reduction in maternal mortality, huge improvements in HIV care and world-leading immunisation against HPV attracted global business, foreign aid and complicity from world leaders. Using women’s health as flattering lighting in Rwanda was too readily condoned because the outcome improved some women’s lives. But as Harman reminds us, authoritarian governments tend to “ration who does or does not get access to health”, exercising its services “by fear not trust”.

Meanwhile, as the largest provider of aid, the US offers assistance with strings attached. Since Ronald Reagan, Republican governments have imposed a “global gag rule” that dictates no foreign organisation can receive money for family planning and reproductive health if they also offer or discuss abortions. US support becomes contingent on women dying from illegal terminations, unwanted pregnancies and complications of childbirth. This coercion worsens a precarious situation as “nearly half the women in the world have no, or very restricted, access to abortion”. As Harman concludes, “women don’t have to die because America sneezes its politics into the world”. But with every rightwing US government, they do.

Even when money flows, foreign agendas distort the true health needs of recipient countries. Not all women are seen as equal. “Saving mothers” is a popular women’s health slogan that has mobilised billions of dollars. Mothers aren’t supported for their own sake, though, says Harman, but rather because they look after young and old. As global philanthropist Melinda French Gates put it: “If you invest in women, they invest in everyone else.” Just as there is a stereotype of virtuous recipients of aid, there is also a cliche of virtuous healthcare delivery: by underpaid or even unpaid local women carrying their communities as “both the fixers and shit-catchers in global health”. Harman emphasises that no health policy would succeed without this invisible workforce. And even among those who are paid, abuse is an inevitable occupational hazard. From Uganda to the UK, clinicians and female employees at every stage of healthcare delivery are at risk, to the point where “violence against health workers needs to be seen for what it is: gender-based violence”.

Reading Harman’s powerful narration and detailed analysis of case after case of women’s dispossession cannot but leave you angry. As Ebola spread, women were sexually abused and exploited by the World Health Organization and Oxfam health workers who were meant to be there to help. Before October 2023, pregnant Palestinian women were dying because of understaffed and underfunded hospitals in Gaza and the West Bank. Forced to use Israeli facilities, women died at checkpoints waiting to get to them. Harman forcefully condemns the alleged targeted bombing of Palestinian maternity hospitals over the last nine months as not just “collateral damage” of war, but a direct attack on Palestine’s future. Global health charities continue to operate without a “charter of patient rights”, which means photographs of vulnerable women taken in moments of desperation can be bought as stock images. To increase charitable donations, female victims are then expected to share their stories with just the “right amount of trauma and redemption” to prompt western women to reach deep in their pockets.

Harman delivers this devastating diagnosis with a powerful prescription for change. I cheered along with her central message that women must be believed and that society needs to be ready to hear their testimony. When sceptics ask: “But what about the men?” Harman underlines that this filibustering should be challenged as a deliberate attempt to distract women. Expertise on gender, such as Harman’s own, needs to be threaded through global health work rather than belatedly added as a rubber stamp. While being careful with our own health data, women should insist on data collection that sincerely tries to understand sex and gender dynamics in places where the world often chooses to look away – whether that’s the stark racial inequities in medical care or impaired quality of life from disability.

I also wanted to agree with Harman’s stance that we should “never advocate for woman’s health as a means to something else” because that is to “devalue the lives and health of women”, but this gave me pause, as a clinician, academic and a patient. What happens in the meantime between the chaos of global women’s health as it is and what it could be? Should all philanthropy that comes with provisos be rejected? Should funding from companies that enjoy the PR boost of helping women as well as their bottom line be criticised? Harman too quickly minimises the work of “counting the women who sat on panels, authored publications and participated in clinical trials”.

And there is value in the 2022 women’s health strategy, despite its many shortcomings, it remains one of the most substantial offerings on the issue in this country for generations. It has improved lives, opened access to contraception and menopause support, to menstrual education and to sexual and reproductive healthcare. For Labour to discard this imperfect piece of work, contaminated as it might be by agendas of the past, would be foolish. Women will be best served by leaders who are prepared to improve what already exists, to fail again and fail better.

Kate Womersley is a doctor and academic specialising in psychiatry. Her work at Imperial College London focuses on sex and gender equity in biomedical research