Spare no effort, struggle unceasingly,

That at last peace may come to our people.

And jeweled dresses and deformed feet
Will be abandoned.
And one day, all under heaven
Will see beautiful women,
Blooming like fields of flowers,
And bearing brilliant and noble human beings.
—Ch’iu Chin, China, 19 th Century 1
 Prologue: Darkness and Light

Being born female is dangerous to your health. This reality may not be true
for many readers, but for most women living in poorer countries2 around
the globe, it is devastating.

The dangers start before birth. Sex-selective abortion is widespread, as

parents decide for various reasons that they cannot bring another girl into
the world.3 Hundreds of thousands of girls have “disappeared,” unbalancing
sex ratios in countries like China, India, and Korea.4 Every person in poverty
is at a disadvantage, but the gender differences are staggering. Seventy-seven
million girls worldwide, compared with sixty-five million boys, do not go to
school.5 Some three million girls, most of them in Africa, are at risk of being
genitally mutilated each year.6 HIV/AIDS is spreading fastest in one popu-
lation: adolescent girls and young women.7 More than 350,000 women die
each year from almost completely preventable childbirth-related injuries and
illnesses.8 One fourth to one half of women worldwide suffer violence at the
hands of an intimate partner.9 Three out of four fatalities of war are women
and children.10 Most older women in poorer countries are illiterate and living
with illness, challenges also faced by many men. But unlike their male coun-
terparts, these women are more isolated (rarely remarrying after the death
of a spouse) and often are saddled with arduous care-giving roles.
Women’s health is so much more than a medical issue; it is cultural,
political, economic, and—above all—an issue of social justice. Improving
women’s health and advancing the status of women is often seen as a pow-
erful means to solve economic problems rather than as a route toward true
xv
xvi outrage to courage

justice. It is both, to be sure. However, I write this book to make the case that
social justice has for too long been eclipsed by concerns for “development.”
My experience indicates that the basic reality of women as “the other,” or as
persons of lesser power (in many senses, not just economic power), emerges
as central; this basic reality is an issue not only of development, but also of
basic human rights. Health issues are one prism through which to view the
human rights of all.
In this book I describe this outrage, the darkness of persistent poverty
and the low status of women, and the scandalous injustices that ravage the
health of poor women in many poorer countries. Yet there is another side
to this story. Change is possible, brought on by the courage of women to
shine a light in the darkness and take action. These efforts are represented
here by the poetry of women and the work of women’s groups. They are also
expressed through the images of the koru used throughout the book. Koru, in
the Maori language of New Zealand, symbolizes not only the unfolding of
the fern frond striving toward the light, but also a new beginning, renewal,
and hope for the future. To fully grasp the depth of women’s courage requires
understanding the outrage in all its heinous aspects, a fact that has led me
to concentrate on describing the details of their plight.

On a trip to Kenya in 2002, I met Janet,11 one of many women who have
left lasting impressions on me and inspired me with hope. In the face of the
systematic attack on the health and rights of women, some remain undaunted.
Janet, a forty-year-old woman who lives in Butula, Western Kenya, is a com-
munity health worker, walking barefoot from village to village to tell others
of the value of being tested for HIV/AIDS, and helping those who test posi-
tive to live fully and those who test negative to stay that way. She has four
children under the age of twelve, has lost her husband to AIDS, and is HIV
positive herself, having contracted the virus from her husband. She earns
twenty dollars a month for her outreach work; not enough to feed, clothe,
and educate her children. “I hope that they will be looked after when I die,”
she says, “I worry about my children, but otherwise my life is good.” I asked
Janet if it had been difficult to be open about her status in a country where
people who are HIV positive or who have AIDS are stigmatized. She told
me that being open about being HIV positive had made her feel free—to
seek help, to live more joyfully, and to help others.
 darkness and light xvii

Janet is illiterate; she is an “ordinary” woman and may even be said to be

“typical” of many women in poorer countries in the world today. Some 26%
of women in the developing world are illiterate (a figure that rises to 45% in
Africa), compared with 14% of men.12 The vast majority of these women are
poor, live in rural areas, and suffer ill health. Great numbers of these “ordi-
nary” women, however, are strong and resilient.  Janet, like many women I
have met around the world, brings light to the world’s darkness, and has found
meaning and fulfillment in her capacity to go beyond herself to help others.
I am a fortunate person to have had the chance to meet people like Janet,
to be inspired by them and to have learned from them. So, too, the students in
my classes at Stanford: their enthusiasm and commitment to positive change
have spurred me to move beyond the classes to describe in this book some of
the outrageous situations of women contrasted with the compelling stories
of women who are making change around the world. Hundreds of students
eagerly learn about the situation of women worldwide and just as eagerly won-
der, “What can be done?” “What can I do?” I hope that by learning about
the situation of women and of the efforts that women’s groups are making
to ensure that life, truth, and light persist in the face of death, untruth, and
darkness, we will join together to try to achieve positive social change.

Critical Issues Faced by Resource-Poor Women

To understand the situation of women’s health in poorer regions, particularly
life-or-death health issues whose outcomes depend on whether women can
exercise their basic human rights—in other words, be empowered—one only
need listen to women at the grassroots levels. At forums, in their writing, in
proposals to donor agencies, and increasingly in interviews with journalists,
they identify the critical issues affecting their lives and their health, which
can be summarized thus:
ƒƒ the demeaning and disempowerment of girls and women
ƒƒ the persistence of poverty
ƒƒ unequal access to education, food, health care, and money
ƒƒ pervasive violence.

This book begins with a chapter on women, poverty, and human rights, for
this reason: If we are interested in transforming our societies by promoting
women’s health, it is important to make the concept of human rights and justice
xviii outrage to courage

central, as the basic context for all of our programs to assist girls and women.
The promotion of women’s health is not just a good economic or development
decision; it is the right thing to do. All aspects of a woman’s life are involved
with her health, especially if we define “health” broadly, as does the World
Health Organization (WHO), as “a state of complete physical, mental and
social well-being and not merely the absence of disease or infirmity.” 13
Subsequent chapters are concerned with the enormity of the world’s
grief as it is expressed through women’s lives—the issues of son preference,
unequal access to education and food, the vulnerability of adolescent girls,
the scandals of maternal injury and illness, the prevalence of violence in the
home and the intensification of sexual violence during conflict and times
of natural disaster, and the reality of unequal access throughout life, into
older age. A current force affecting women’s health is the economic power
of globalization, which is explored in Chapter 8, in the context of women’s
labor and need for access to the cash economy. The ways that environmental
health issues, particularly having to do with water and fuel, affect women
are raised in the eighth chapter as well.
The universal and under-studied problem of mental health is highlighted
toward the end of this Prologue and raised throughout the book. “We women
worry too much!” as Avotri and Walters quote in their study of Ghanaian
women’s perceptions of their health.14 Yes, we do, though that can be both
an unhealthy behavior and one that spurs us to action.
Examples of some of the thousands of community-based women’s orga-
nizations addressing these health and human rights issues are included at
the ends of the chapters to highlight the strength of women like Janet and to
provide hope for change.15 To provide context for the descriptions of wom-
en’s groups that serve as illustrations throughout the book, a final chapter
describes women’s activism and the international women’s movement and
offers some thoughts for the future. Some fifty new examples of women’s
groups are included in this second edition of the book.
Through stories and descriptions, poetry and statistics, I seek to aug-
ment the overview provided by this book. Many issues of women’s health
have long been invisible, and considered too “private” to discuss. Here we
try, as Gandhi counsels, to “make injustice visible.”
 darkness and light xix

Who is Worth Studying?

Few books focus on the situation of women and their health globally, though
some describe specific health topics and health status in general. All too
often there is no mention or description of how many issues (violence, HIV/
AIDS, and aging, for example) affect women and men differently. Some of
this neglect is a carryover from earlier times in which women were not stud-
ied, and the situation of men, mostly white men, was seen to be the norm or
standard against which to measure others. Some of the neglect is simply a
reflection of priorities: who and what is worth studying?16
In the book Engendering Health Equity, Gita Sen and her colleagues
explain that although public health researchers have been concerned with
health inequity (mostly based on determinants such as class or race) since
the early nineteenth century to the present, there is still not significant
study of gender-based inequities in health.17 Early in their book they suggest
that it is important to pay attention to health differences between men and
women for the simple reason that differences do exist. They write: “Despite
these empirical differences and growing attention to health inequity gen-
erally, it has taken much longer for gender to be recognized as a contribut-
ing social factor than, say, socioeconomic class, race, or caste. In part this
is because of the still common fallacy of conflating gender with biological
difference.” 18 They explain that when one refers to gender one looks beyond
biological differences to understand the deeper social foundations of power
and inequality. The authors write (and I have taken to heart in this book):
“Understanding the way in which biological and social factors interact in
different aspects of health becomes central to our understanding of how
gender operates in health.” 19
Many of the topics raised here have not been studied extensively and
therefore appear to be “new,” even though they may represent “tradition”
in some countries. To discuss such issues, I have drawn from a diversity of
sources, including the publications of multinational agencies and grassroots
women’s groups, journalists’ accounts, and academic studies, where they
exist. Some studies on the situation of women were done in preparation for
the Fourth United Nations Conference on Women held in Beijing, China,
in 1995, but since that time relatively little money has been made available
to enable formal research and analysis on the situation of women and their
health worldwide and in individual countries. Journalists’ accounts, some
xx outrage to courage

UN statistical material, and applied studies by women’s groups offer some

information and current perspectives. Where relevant, statistics were updated
for the second edition of this book, primarily using United Nations sources.

Turning a Blind Eye to Key Issues

How is it that women’s health—the situation of about half of the world’s popu-
lation—has failed to be a focus of study? Here are some thoughts about why
there is limited financial support and very little research on certain topics.
ƒƒ Female infants’ and children’s access to food and/or medical care has
been neglected because researchers either view the household as a single
entity with uniform internal distribution or treat newborns as a sex-
neutral category.
ƒƒ Beyond a focus on fertility/childbearing behavior, the health lives of
adolescents have not been studied extensively, perhaps because of a pre-
occupation with population pressure and sexuality.
ƒƒ The extent of sex trafficking has been little known, perhaps because
this phenomenon is tied in intricate and hidden ways to international
corporate and business interests.
ƒƒ Until very recently, the special vulnerability of women in war and
refugee situations has been seen to be a “natural” byproduct of war—
“collateral damage.”
ƒƒ Almost no attention has been given to older women in poorer countries,
perhaps because, in the scheme of things, older women have been con-
sidered unimportant and unproductive.
ƒƒ The mental health of women and girls (and men and boys) in poorer
countries has been virtually unstudied, probably because of the difficul-
ties of definition and the overwhelming nature of the problems.

In short, until very recently, little was studied—and therefore learned

about—women in poorer countries, beyond their roles as producers of chil-
dren and as mothers. Even the issue of violence against women within the
home and community—so central to women’s health—was taboo until the
past ten to fifteen years.20
Much of the violence that has been done to women and girls has been
invisible or taboo. Certainly it has not been accessible to outsiders in many
 darkness and light xxi

societies, particularly those where women’s place has not been public but
always private, closed, behind doors. A man’s home is his castle, in which
live women and children—the “subjects” of the lord and master—whose lives
are not to be seen. Private, secret things go on behind the walls. This sepa-
ration of the “public” and “private” spheres has resulted in injuries inflicted
on women and children in private not being viewed as human rights abuses
and essentially remaining invisible. These have included such violations as
unsafe childbirth practices, female genital mutilation, the buying and selling
of young girls, honor killings, dowry deaths, and domestic violence.

The Lens of Mental Health

As briefly mentioned above, the issue of mental illness is another that has been
understudied and underfinanced, especially in resource-poor countries. The
widespread prevalence of mental illness is an overarching theme in women’s
health, and indeed the health of all people. As such, mental health can be
used as a lens through which to examine or re-examine the issues in this
book, as most or all have crucial mental health components.20
Just how common are mental health disorders? According to the WHO,
mental and substance use disorders accounted for 13% of the global bur-
den of disease in 2002; depression alone is predicted to become the second
highest cause of disease burden worldwide by 2030, surpassed only by HIV/
AIDS.22 Already, depression is the single largest source of disability, estimated
to account for 31% of all years lived with disability.23,24 The prevalence of
certain mental illnesses, in particular depression and most anxiety and eat-
ing disorders, is significantly higher among women—a ratio of 1.5:1 or 2:1
(women with the disease to men with the disease) is typical.25
A small part of this increased risk in women can be attributed to biolog-
ically-based sex differences between women and men: for example, rapidly
changing hormone levels in pregnancy and in the post-partum period increase
women’s likelihood of developing a mental illness.26 However, for the most
part, women’s predisposition to mental health disorders is mediated by socio-
economic factors. A 2007 paper in the medical journal The Lancet examined
the risk factors driving this higher prevalence in women, stating: “Gender
affects many of the determinants of mental health, including socioeconomic
position, access to resources, social roles, rank, and status; and gender dif-
xxii outrage to courage

ferences in mental disorders diminish after controlling for these mediators

(emphasis added).”27 The extremely differential risk of mental illness among
women and men, therefore, is primarily driven by “the gendered disadvantage
experienced by women in many parts of the world.”28 A widespread shortage
of mental health professionals in the developing world only exacerbates the
problem, limiting women’s access to treatment.29
Nearly every critical issue women face over the life course is associ-
ated with mental illness. Early age at marriage (discussed in Chapter 4) was
found to be strongly associated with common mental disorders in a survey
in Goa, India, as was intimate partner violence and abuse (Chapter 6);30 in
general, the health consequences of gender-based violence include a host
of mental health and behavioral problems. Women in conflict and refugee
situations (Chapter 7) have an especially high risk of developing mental ill-
ness: the rate of mental health disorders in a community tends to double
after a war or other major disaster.31 Sex trafficking, a focus of Chapter 8,
produces devastating emotional and psychological effects, and many women
turn to alcohol and drugs to deal with this psychological pain. In old age,
discussed in Chapter 9, the prevalence of mental illness tends to increase
still further.32 Individuals who are older, female, widowed, and report poor
physical health are more likely to report worse mental health outcomes,33
and the latter two risk factors tend to correlate among older women. HIV/
AIDS presents a special mental health burden to older people, faced with
the devastation and loneliness of losing their children along with the stress
of raising grandchildren.
Thus, mental health is highly interconnected with women’s low socioeco-
nomic status overall, as well as with the specific issues women face as a result
of that lower status. Addressing mental health, and recognizing the men-
tal health aspects of so many health problems, is vital; as the World Health
Organization so concisely states, “There is no health without mental health.”34

When we look at women’s lives and their health from infancy through old
age we are stunned by the degree of injustice and outright harm that occurs.
Governments struggle to provide for their people in the face of many con-
flicts and very difficult economic circumstances. Tough choices are made at
the government, community, and family levels, choices that directly affect
 darkness and light xxiii

the health of individual men, women, and children. The situation is dire,
and it is easy to be dragged down by the difficulties that face many societ-
ies and individual people these days. Reading the daily newspaper can be a
“downer,” as we learn of corruption and lying within governments and cor-
porations, the slaughter and rape of innocent villagers in war-torn countries,
the competition and greed that drives officials and so-called leaders, and the
violence that characterizes our time.
Despite many indications, however, there is a lot of good news, much of it
going unreported in a media structure bent on emphasizing despair. Women
in Afghanistan gather together to cast their votes, risking public ridicule. A
village woman, Mukhtaran Bibi, in Meerwala, Pakistan, chooses to take a
gang of rapists to court rather than to commit suicide out of shame, and she
receives the support of women’s groups in her country and beyond. Young
women, in particular, take leadership in Egypt and other parts of the Middle
East during the “Arab Spring.” Local groups of women in Chennai, India,
turn up at the home of a victim of domestic violence to silently but publicly
shame her attacker. Grandmothers in Mali and Senegal add orphans to their
already heavy load of responsibility; they meet to strengthen one another.
Seldom reported are the amazing accomplishments of individuals and
groups at the grassroots level of societies. Women’s groups, in particular, have
proliferated in every country in the world. People are coming together with
strength in villages and cities to address practices rooted in tradition (such as
female genital mutilation and early marriage) and problems exacerbated by
current forces (such as trafficking of women and girls and unhealthy labor
practices). Examples of such initiatives appear throughout this book.
Around the world the rights of individuals are increasingly being rec-
ognized. With the promulgation of the Universal Declaration of Human
Rights in 1948 and subsequent conventions and actions of the United Nations,
individual people and governments are beginning to accept the possibility
of change.35 Furthermore, as civil society grows in strength, in the form of
thousands of  “third” sector (non-governmental, not-for-profit) organizations,
and in particular women’s groups, movements for social justice are becoming
stronger and marginalized people are demanding their rights.
The descriptions throughout this book provide hope that poor women
working to create change—even against overwhelming odds—constitute a
strong and inevitable force. To ensure their success, we need to learn from
xxiv outrage to courage

them, join them, and be there for them at home and globally. I take guidance
from this quote from the Talmud: “Do not be daunted by the enormity of the
world’s grief. Do justly, now. Love mercy, now. Walk humbly, now. You are
not obligated to complete the work, but neither are you free to abandon it.”
The way we do our work is key. By never failing to put justice at the center
of our efforts, we can realize the hope that Ch’iu Chin offered a hundred
years ago—that “one day, all will see beautiful free women.”