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Excerpt: 'The Means Of Reproduction'


Eunice Brookman-Amissah, the former health minister of Ghana, calls the death of her teenage patient Amina the beginning of her road to Damascus. The stepdaughter of an Anglican archbishop, Brookman-Amissah was brought up in a very conservative home, and those values stayed with her when she went to medical school. In the Accra teaching hospital where she trained in the late 1960s, young women who came in with botched abortions were put in a place called Chenard Ward. There were at least ten of them every day. "They were kept there bleeding and feverish and dirty until all the other cases were done-- then it was time to do the evacuations," she told me. "They were kept on the floor. Even when there were beds, these women were put on the floor. People stepped on them and insulted them and called them names-- this is how horrible it was!"

Brookman-Amissah did not, at the time, see all this as particularly outrageous. "We were brought up to think that women who had had unsafe abortions were criminals," she said. "They were bad women. They were the scum of this earth."

After graduating, Brookman-Amissah went into private practice. She looked after a poor Muslim family who lived very close by. Their daughter, Amina, was exceptionally bright. "Her parents were illiterate, but she was going to school," Brookman- Amissah said. Amina called her "Auntie Doctor," and liked to hang out at her clinic and talk to the nurses, saying she would be one herself one day.

In 1992, when Amina was fourteen, she came to the clinic one Friday. As Brookman-Amissah remembers it, she was agitated and had been crying. A man in her compound, she said, had given her money to give to a doctor to make her period come. "My first reaction was one of outrage," said Brookman-Amissah. " 'Amina, how dare you talk to me about that? Don't you know we don't do that here! Naughty girl!' That sort of thing." Brookman-Amissah asked Amina to send her mother on Monday so they could talk. "I can still see the look in her eyes," she said.

But on Monday, no one came. Nor on Tuesday. On Wednesday, she heard drumming and commotion outside. A nurse told Brookman-Amissah what it was. "Doctor," she said, "that's Amina. They've gone to bury her." The man who got her pregnant had taken her for an abortion over the weekend, and it had killed her.

"Was Amina really a criminal?" she remembers thinking. "Maybe I'm the criminal. That man, that older man, is a criminal. The whole society is liable for the death of an innocent young girl who didn't even know what was happening to her."

Brookman-Amissah began to alter her views. She got involved in training doctors in more humane post-abortion care, and eventually became the representative in Ghana of Ipas, an international safe-abortion organization based in Chapel Hill, North Carolina. Ipas distributes manual, handheld abortion kits all over the world, which are also used to treat women whose backstreet abortions have gone wrong. Brookman-Amissah used to sit for hours outside the offices of the Ministry of Health, trying to donate the kits and to offer free training in their use. "I believe I was called the abortion lady," she said.

Yet while abortion remained illegal, the mood was changing among elites. Brookman-Amissah remembers that when she proposed programs to address complications from unsafe abortions, the woman who headed the government's office of reproductive health was unsure. Then the official went to a groundbreaking 1994 UN conference in Cairo, during which, much to the chagrin of an international network of religious fundamentalists, most of the world's countries pledged to commit themselves to reproductive health and rights. She came back clutching the conference's official program of action, which urged all countries "to deal with the health impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family- planning services."

Soon Ipas and the Ghanaian government were collaborating on a program to train midwives to help women who'd suffered complications from illegal abortions. And then, in 1996, Brookman-Amissah became the minister of health herself. Later she would become Ghana's ambassador to The Netherlands, before rejoining Ipas as vice president for Africa. Abortion remains broadly illegal in her country, but the government is actively trying to educate workers in health care and law enforcement that there is an exception when a woman's health is at risk.

Promoting safe abortion in Africa is a monumental job. Thanks to the legal remnants of colonial constitutions, the procedure is severely restricted in most sub-Saharan African countries. According to the World Health Organization, of the forty-two million abortions performed in the world each year, twenty million are unsafe, and nowhere in the world are abortions more dangerous than in Africa. Botched abortions kill 36,000 African women each year, representing more than half of the global total of between 65,000 and 70,000 annual deaths.

Worldwide, complications from unsafe abortions cause 13 percent of maternal deaths and account for a fifth of the "total mortality and disability burden due to pregnancy and childbirth," according to the WHO. Twenty-four million women have been rendered infertile by dangerous procedures, an especially crushing debility in parts of the world where childless women are reviled. Again, the toll is worst in Africa.

The problem of unsafe abortion is seriously exacerbated by contraceptive shortages caused by American policies hostile to birth control, as well as by the understandable diversion of scarce sexual health resources to fight HIV. Between 1995 and 2003, international donor support for family planning in the developing world fell from $560 million to $460 million, a shortfall that has hit Africa particularly hard. In Kenya, the World Health Organization reports, between 1998 and 2003, the number of births that mothers said were unwanted nearly doubled, from 11 percent to 21 percent.

But it's not just the scale of the problem of unsafe abortion and lack of family planning that makes the work of reform so difficult. Cultural conservatism is deeply entrenched across Africa, as it is in most of the poor regions of the world. Religious revivals, Christian and Muslim alike, have caught fire, and they compete to condemn the destabilizing libertinism of the West. (During the American presidential campaign of 2008, the Ghanaian artist Blakk Rasta had a hit with the song "Barack Obama," which celebrated the candidate even as it promised that judgment would come to America for "legalizing abortion." Churches in the global South "are by and large much more comfortable than their Northern neighbors in preaching a traditional role for women,"wrote the religion scholar Philip Jenkins in The Next Christendom: The Coming of Global Christianity. "This is especially true in much of Africa, where Muslim notions exercise a powerful cultural influence. Although Christians do not accept the whole Islamic package of mores on this or any issue, they do imbibe a conservatism general to the whole community."

The specific religious dynamics differ in other parts of the planet, but the conflation of women's rights with globalization or Westernization, and the concomitant desire to limit them in the name of national or cultural integrity, is nearly universal. Republicans in the United States, whether in Congress or the White House, have worked to bolster this conservatism by denying aid to groups that have anything to do with abortion, channeling funds to traditionalist faith- based groups, and using the country's diplomatic weight to thwart international efforts to improve reproductive rights.

American antiabortion pressure, said Brookman-Amissah, "has grown over the years. It started with resistance to the whole Cairo agenda, especially the reference to reproductive health and rights, a word they seem to be very allergic to. The fanaticism that is there about abortion, which is also threatening women in your country, this was translated onto the international scene." Even as religious traditionalists in developing countries find support abroad-- whether it comes from Saudi Arabia, American evangelicals, or the Vatican-- they excoriate feminists and family planners as agents of Western cultural imperialism. Meanwhile, women's rights activists like Brookman-Amissah find bases for their work in international NGOs (nongovernmental organizations), and backing for their positions in statements of the United Nations and other international bodies. A global culture war is raging, and it's all about who controls women's fertility-- and, more broadly, women themselves.

That is the subject of this book-- the global battle for reproductive rights. It spans five decades and four continents, and it elucidates a multifaceted political and ideological fight that is one of the most important, if unsung, of our time.

All over the planet, conflicts between tradition and modernity are being fought on the terrain of women's bodies. Globalization is challenging traditional social arrangements. It is upsetting economic stability, bringing women into the workforce, and beaming images of Western individualism into the remotest villages while drawing more and more people into ever growing cities. All this spurs conservative backlashes, as right- wingers promise anxious, disoriented people that the chaos can be contained if only the old sexual order is enforced. Yet the subjugation of women is just making things worse, creating all manner of demographic, economic, and public health problems.

This is not just a story about abortion, though abortion tends to be a flashpoint It is, rather, about how great international powers have worked to influence the rights of the world's women, and how, conversely, women's rights will ultimately shape the future.

The tale is much bigger than it might at first appear. For decades now the countries of the first world have been exporting family planning to the third world, for reasons that combine humanitarianism and national security realpolitik. With the West's help, governments worldwide concerned with overpopulation have tried to change the sexual and childbearing norms of their peoples. Feminists have fought, with a surprising if unheralded degree of success, to have reproductive rights recognized in international law. The United States has, depending on who is in charge, worked to bring safe abortion to poor countries, and worked with equal zeal to take it away. Imitating the organizing strategies of their opponents, fundamentalists have joined hands across national borders to stave off challenges to traditional gender hierarchies. And remarkably little of this hugely consequential story is understood by the American public, despite the country's crucial role in shaping the fate of women all over the planet.

Many of the roots of our current battles lie in the cold war, a time of widespread panic that overpopulation was going to lead to Malthusian doom and revolutionary upheavals. Back then, staunch anticommunists saw the mass diffusion of birth control as a key bulwark against anticapitalist chaos. A huge international family planning infrastructure was erected, and the idea that childbearing should be a matter of choice rather than fate spread throughout the world.

Not surprisingly, some countries saw this as a form of neocolonialism, a critique that has gained ever more salience in recent years, when it's been supported, ironically, by the American right. Nevertheless, in the second half of the twentieth century, a global consensus began emerging that overpopulation hindered development. As the concern grew, some countries started using coercion to bring down birth rates faster, resulting in outcries from both feminists and religious groups.

At certain points there was considerable hostility between those most concerned about women's rights and those most worried about overpopulation, groups whose aims now appear deeply intertwined. In the 1970s, though, a group of feminist-minded women who had come up through the ranks of the population-control movement decided to take it over from within. They argued that you couldn't treat women as mere means to a preferred demographic destiny; their rights and health had to be ends in themselves. If overpopulation was a problem, its root cause lay in women's subordination, which too often gave them little choice over how many children to have and almost no social value outside of reproduction. Women needed power, not just pills, and population programs could be harnessed to improve their health and status. Employing canny bureaucratic warfare, skillful organizing, and a solidarity that transcended borders, these women worked within emerging systems of global governance that, even today, few outsiders understand. As a result of their efforts, at the 1994 International Conference on Population and Development in Cairo, their once marginal views about the universal importance of reproductive rights became the official policy of the United Nations. It was a policy that was supported by every major donor country, including, at the time, the United States.

Religious conservatives in many regions were alarmed by this, and sometimes banded together across sectarian lines in opposition. At one point, as we'll see, Pope John Paul II even offered to help Libya achieve a rapprochement with Western governments in exchange for standing with the church against reproductive rights at the UN. When George W. Bush entered the White House in 2001, the fundamentalist alliance achieved an unprecedented level of power and influence. The global reproductive rights movement, though, had also grown strong, and found it could survive the defection of the United States, its original patron. Reproductive rights even entered the realm of internationallaw when in several significant cases courts ruled in varied jurisdictions that women who had been denied abortions had had their human rights violated by their own countries.

Some of this might sound abstract. Debates in congressional hearings, foundation boardrooms, and international conferences can seem far removed from women's real lives. On the ground, though, the consequences have often been profound, determining, among other things, whether a woman has access to contraception and, if she needs it, an abortion; whether she can get an education before she starts her family and earn an income after; whether her government penalizes her for having what it deems too many children; and whether her genitals are left intact or ritually circumcised to encourage her chastity.

In reporting on controversies in Latin America, Africa, India, and Europe, I tried to portray women's stories in all their complexity, without attempting to tie up every ideological loose end. Unlike the brilliant philosopher Martha Nussbaum, I'm not attempting to create a universal framework of women's rights or to systematically disentangle transcendent values from culturally specific ones. If anything, I'm often trying to show how difficult it is to do just that. Real lives have a way of defying neat political categories, and of refusing to embody pat lessons. Grand plans to remake societies, no matter how well intentioned, usually have unintended effects. Nevertheless, ambitious efforts to improve the health and status of women have at times been quite successful, as have campaigns to roll them back.

Ultimately, one insight that I hope emerges from these stories is that feminists, liberals, and reformers have as much claim to cultural authenticity as conservatives do. To act as if only the most static and rigid parts of a culture are genuine, to treat other societies as less capable of dynamism and progress than we in the West believe ourselves to be, is deeply condescending to the women all around the world who are trying to effect change from within. I've been guided by the belief that we should show solidarity with people who aspire to be protected by the same universal human rights guarantees that we enjoy.

In almost every country on earth there are internal struggles over the role of women, fights that pit universalist claims for women's human rights against cultural relativist arguments for preserving traditional gender relationships. Indeed, women's rights are perhaps the most visible sign of modernity and thus an obvious bête noir for flourishing fundamentalist movements. In developing nations the situation is further complicated by the influence wielded by international donors, aid agencies, and UN bodies that work to promote reproductive rights, inevitably affecting sexual norms.

In 1984, the brash, flamboyant feminist Germaine Greer published Sex & Destiny: The Politics of Human Fertility, which is, among other things, a broadside against the ethnocentrism of the international family planning movement and a fetishization of traditional village life. "The majority of the world's women have not simply been entrapped into motherhood: in societies which have not undergone demographic transition, where children are a priceless resource, the role of mother is not a marginal one but central to social life and organization," Greer wrote. This is absolutely correct, and it is the reason feminists once fought population controllers who ignored women's own hopes and desires.

Nevertheless, women everywhere do try, sometimes desperately, to limit their fertility, a fact borne out by their frequent recourse to abortion. In hymning traditional social arrangements, Greer moved so far to the left that she circled around to the right, treating every society but her own as a harmonious, homogenous system that could only be distorted by the malign influence of Western liberalism. Written at a time when she was herself struggling with infertility, Greer charged family planners with spreading the antichild ethos of a selfish, materialistic, and maladaptive modernity. Further, she defended the chador, extolled chastity over artificial contraception, and posited patriarchal peasant society as preferable to individualistic consumer capitalism. "One of the most insidious forms of pollution is the destruction of the integrity of one's culture by that of another, dominant, outsider group," she wrote, "and it is under such conditions of cultural resistance that adherence to cultural standards of purity becomes most important; it is part of taking the line of most resistance, whether to lipstick, Coca- Cola, opium, or oral contraceptives." As an observation, this is true enough; it's part of the reason that, for example, some humiliated Muslims have taken refuge in a medieval fundamentalism. Greer, however, wasn't just describing such cultural resistance; she was endorsing it. There was no place in her analysis for women who dissented from conservative forces in their own societies, women who longed for the freedoms she blithely dismissed. Writing about women taking up the veil after the 1979 Iranian revolution, she assumed that they had all done so willingly, as a sign of "liberation through self- discipline." Male domination is bad, she allowed, but the patriarchal family is preferable to the atomism of the "consumer economy." Wrote Greer, "To have rejected patriarchal authority within and without the self, however desirable in itself, is to have become vulnerable to much more insidious and degrading forms of control."

Greer made a common error of the disillusioned Western radical, projecting onto other cultures all the authentic virtues she wished were in her own. In thinking about the situation of women in vastly different contexts, there are a number of dangers. One is assuming that Western ways are self-evidently superior and that all women would choose them, if only they could. But another is assuming that women in other cultures are so different from us that situations we would find intolerable-- bearing child after child into grinding poverty; being utterly at the mercy of fathers, husbands, and brothers; having one's clitoris sliced off with a razor-- do not also cause them great pain. The search for human commonality among vastly diverse people is tricky and elusive, but it is callous to surrender to relativism when so many women are clearly suffering.

For people living in the world's rich developed countries, it can be hard to grasp just how terribly women are treated in much of the world. Sexism and violence exist everywhere, but political correctness or condescending romanticism about exotic others should not obscure the fact that women in the third world often have it much, much worse.

In large parts of Asia girls are given less food and medical care than boys from infancy. Throughout Asia and Africa they are significantly less likely than boys to be enrolled in school. More than a third of girls worldwide are married off before they reach adulthood, often to much older men. Early pregnancy taxes their bodies; girls under fifteen are five times more likely to die during pregnancy and childbirth than women in their twenties. Obscenely high rates of maternal mortality are a global scandal, taking more than half a million women each year, 99 percent of them in the developing world. One in twenty-six women in Africa will die of pregnancy-related causes.

In many countries women have no rights to their husband's property, and should they be widowed, they can be either thrown out of their homes or inherited by their husband's brother. The lack of power that women have over their own bodies is directly responsible for the feminization of the AIDS epidemic, which in Africa is killing far more women than men. In 2004, when Ugandan feminists tried to pass a bill that would, among other things, ban spousal rape, men reacted with outrage. A member of the Ugandan parliament's legal affairs committee said the bill should address women's denial of sex, arguing, "Refusing to have sex is the most violent thing a spouse can do."11 There are many parts of the world where domestic violence is the rule, not the exception: Seventy-one percent of women in one rural Ethiopian province, 69 percent in one rural province in Peru, and 62 percent in a province in Bangladesh say they've been abused by a partner.

Writing about women's rights globally can be complicated for an American, since it can seem both condescending and like an alibi for imperialism.There is, after all, a long history of Western colonialists justifying themselves by promising to liberate benighted native women. In 1927, an American journalist named Katherine Mayo wrote a best-selling book called Mother India about the degraded position of females in that country. India's ills, she argued, had nothing to do with British rule and everything to do with child marriage and the oppression of women, which led sickly, ignorant mothers to raise devitalized, sexually perverse children. "The whole pyramid of the Hindu's woes," she wrote, "material and spiritual . . . rests upon a rock- bottom physical base. This base is, simply, his manner of getting into the world and his sex- life thenceforward." At a time of mounting Indian nationalism she argued that the sexual organization of Indian society made self-rule impossible.

Mayo's book became a sensation in both England and the United States-- there was a Broadway play based on it about a twelve-year-old Indian girl married off to an old man-- while Indians so reviled it that some demanded it be banned. Wrote one Indian historian, "Even today, few books-- apart, perhaps, from Salman Rushdie's Satanic Verses (1989)-- can match the scale of the international controversy generated by Mother India."

Many decades later U.S. neoconservatives used Islamist abuses of women-- which are, of course, quite real, as were many of the atrocities documented by Mayo-- to justify American aggression in the Middle East. (Few, of course, suggest punishing friendly Saudi Arabia for its system of gender apartheid.) It is not surprising, then, that there is abundant suspicion in the developing world whenever Westerners begin cataloguing the ills visited on foreign women. However, that suspicion, and the history that gives rise to it, does not change the fact that the widespread, overwhelming abuse and devaluation of women, especially in poor countries, is the biggest human rights crisis in the world today.

Given the range of horrors to which women are subject, perhaps it's fair to ask why focus on reproductive rights at all. Access to contraception and abortion are obviously not all that's needed for equality. The right to work and go to school, to own land, to inherit, to live free from violence-- these are life and death issues for many women in developing countries. They often have far more day- to- day salience than family planning.

Yet reproductive rights are the place where many of the crucial forces shaping and changing women's lives-- religious authority, globalization, patriarchal tradition, demographics, American foreign policy, international law, environmentalism, and feminism-- intersect. They are the ground on which major battles about women's status are being fought. And a woman's right to control her own body, to make her own decisions about childbearing, is closely bound up with other rights in myriad ways, as we'll see throughout this book. For one thing, reproductive rights are intimately related to women's economic freedom. Having smaller families allows women to work. When they bring financial resources into the family, their power tends to increase and their daughters' welfare improves. When their daughters are educated, they also choose smaller families, which can be better cared for. As a paper by the World Health Organization put it, "The reproductive revolution-- the shift from six births, of whom several might die, to around two births, nearly all of whom survive-- represents the most important step toward achievement of gender equality by boosting women's opportunities for nondomestic activities." That's part of the reason that Bangladesh's famed Nobel Peace Prize–winning Grameen Bank, which makes microloans to poor women, has borrowers pledge to "plan to keep our families small."

At an even more elemental level, for far too many women pregnancy is either deadly or debilitating. Putting off childbearing until their bodies are mature enough protects mothers, as does spacing their pregnancies several years apart and having only as many children as they choose. Furthermore, it makes little sense to tackle maternal mortality and morbidity without paying attention to unsafe abortion, one of its major and most easily eradicated causes. Reproductive rights are not the whole of women's rights, but they are a precondition of them. They help women survive and allow them to transcend mere survival.

They are also powerfully symbolic, because women's reproductive role is often the justification for their subordination. International debates over family planning have as often as not become political battles over women's rights more generally, and even over women's humanity. Thus, reproductive rights, while being enormously consequential in and of themselves, also offer a lens through which to view even bigger questions of gender and power in a globalized but desperately unequal world.

From the anticommunist genesis of America's attempts to stem population growth in poor countries to the current worldwide attack on women's rights as a decadent Western imposition, the politics of sex and childbearing are woven into many of the great issues of our time. Underlying diverse conflicts—over demography, natural resources, human rights, and religious mores-- is the question of who controls the means of reproduction. Women's intimate lives have become inextricably tied to global forces. At the same time, the fate of the planet has become inextricably tied to women's ability to control their own lives.

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Michelle Goldberg