Cultural Arrogance, Cultural Naïveté Hurt Efforts to Improve Health Care for WomenPublished: July 27, 2005 in Knowledge@Wharton
While participants in the recent "Penn Summit on Global Issues in Women's Health: Safe Womanhood in an Unsafe World" agreed that gender disparities affecting access to health care are a major problem, they also cited an often overlooked, but just as detrimental, barrier to women's health -- the West's cultural naïveté when trying to "fix" problems in other parts of the world.
In her opening remarks to the two-day summit, Judith Rodin, former Penn president and current president of the Rockefeller Foundation, addressed the kind of burnout that accompanies a problem as all encompassing as a woman's right to safety and health. "This is a much-needed discussion," she said. "No matter how many meetings there are, somehow we have not been able to collectively move the agenda forward." Rodin said that in hosting the summit, the two schools were doing what any university has a responsibility to do: "expanding our understanding and our knowledge, helping to focus and push us," and ultimately to "galvanize energy" for the cause. "There is so much we can accomplish," she noted. "I am confident we can create a culture of safety for women, a culture that recognizes that safety, education, employment and human rights all affect women's health."
In invoking culture, Rodin put her finger on one of the main hurdles to the West's ability to bring about change in developing nations. Speaker after speaker, from 32 countries in all, addressed the kind of cultural naïveté, or arrogance, as some labeled it, that leads to ineffective health care policies.
Susan Watkins, professor of sociology at Penn, approached the problem from a sociological perspective, asking participants to reflect on whether data about women's health is adequately collected. If researchers listen to conventional wisdom, she noted, they often go down the wrong path. For example, conventional wisdom says that the response to HIV/AIDS in sub-Saharan Africa has been silence, denial and fatalism. Not so, according to her research on women in Malawi.
Having followed the same group since 1991, Watkins sees a very active group of women who are keenly aware of the ravages of AIDS. Contrary to conventional wisdom, which holds that young single women are at higher risk for AIDS, the married women in Watkins' study were at far greater risk of infection. "Married women understand very well the issues of AIDS," she said. "They know they are at risk and they are not sitting there in silence."
Watkins documented conversations women had with one another, whether at the local water source or in small groups. What she found was a complex set of issues that could not simply be resolved by the Western panacea of "give them condoms." Women in Watkins' study did not want to use condoms for a number of reasons, including the fact that many wanted to have children (women's fertility is valued in most African nations) and many were afraid their husbands would leave if forced to use condoms.
The women followed by Watkins had very active peer-to-peer discussions about AIDS; their main strategy was to advise fidelity to their husbands. Concluded Watkins: "We simply don't have enough research on what women are saying to peers and what they are doing to help themselves. Unless we know [this], we can't really serve their health needs."
Geeta Rao Gupta, president of the International Center for Research on Women, echoed this in her own discussion of how Western nations, in an effort to stem the spread of AIDS early on, inadvertently made a bad situation worse. "We knew that sex workers were the most vulnerable and we targeted them for interventions," she said. As a result, prostitutes -- as well as the disease itself -- have become highly stigmatized in African nations, making it harder to identify and help those at risk.
She referred to a classic case where a non-governmental organization went into an African village with a project to curtail mother-to-infant HIV transmission. The organization tested all pregnant women for AIDS and gave those who tested positive large cans of formula, advising them not to breast-feed their infants. After several months the organization realized that many of the cans had been thrown into trash bins or left outside the clinic. Only after further inquiry did they realize that the cans themselves were a clear indication that a woman was infected. Even though she most likely contracted the disease from her husband, walking back into her village with the cans brought shame to her and her family.
Such incidents occur frequently when Western culture brings ideas to the developing world, according to speaker Peter Berthold, professor of restorative dentistry at Penn's School of Dental Medicine. Indeed, he said, "to crash another culture with only the vaguest notion of its underlying dynamics reflects not only a provincial naïveté but a dangerous form of cultural arrogance." Berthold's observations stem from his work with Noma, a largely forgotten disease that originates in the oral cavity and results in disfigurement and often death.
Although it can be treated with a simple antibiotic if detected early, a simple antibiotic is not the only answer. In many West African countries, where Noma is prevalent, people infected with the disease are seen as "cursed" and are often left to live with animals or forced into a life of begging or prostitution. Berthold and his team, through the auspices of the World Health Organization, worked to educate traditional healers about the disease, employed "culture brokers," and conducted village-wide trainings. The antibiotic is not the silver bullet in this case, he explained. It is just part of an overall care plan that must include recognition of, and respect for, cultural norms.
Separate Codes of Conduct
The world may be a global village, but it is made up of many different neighborhoods with their own codes of conduct and values. To say "AIDS is an African problem" ignores this fact, said Unity Dow, high court judge in the Republic of Botswana. In comparing the AIDS situation in Sierra Leone to the situation in her own country of Botswana, Dow showed how essential it is for aid organizations to understand the specific "neighborhood" in which they are working. She pointed out that in Botswana, 90% of children are schooled, clinics are available to women, widows inherit land, condom use is high, and there has been no civil war since the country's independence. Yet despite these advantages, AIDS infection rates are higher there than in Sierra Leone, one of the poorest countries in the world, where 70% of the population is malnourished, men inherit and own land, and civil war has raged for the past 10 years. This conundrum shows that "solutions for one country are not the same solutions for others," she concluded.
Dow didn't offer specific reasons as to why AIDS rates are higher in Botswana, although she did cite some possible contributing factors. She suggested, for example, that the stigma attached to AIDS is much higher in Botswana than elsewhere, which means that people don't seek help as readily as in other countries.
Closer to home, the Summit also stressed that biases and stereotypes adversely affecting women's health are not just found on foreign soil. Janice Asher, clinical director of women's health at Penn's Student Health Service, suggested that the tendency to think that rape or sexual assault only happens to "other people" or "uneducated people" is to deny a reality that she sees every day. "Who are my patients?" she asked. "They are the best and brightest, the richest; they are students of an Ivy League university' and at least one-quarter will have had sex against their will." When rape victims enter her office, without fail each one says the same thing: "It was my fault." And bystanders, without fail, say the same thing: "She should have known better" or "He's a good guy; he only does bad things when he's drunk."
At the core of Asher's comments and the entire Summit itself is this question: What happens when 50% of the population lives in an unsafe environment? In her opening remarks, Penn president Amy Gutmann pointed out that "hundreds of millions of women lack access to basic human rights, education, employment and health care. As a result, many women become victims of violence, cultural stigma and poor health." Indeed, many speakers asserted that the right to health is a basic human right and must be treated as such.
Keynote speaker Mary Robinson, former president of Ireland, former United Nations High Commissioner for Human Rights, and executive director of The Ethical Globalization Initiative, believes the role of academic institutions like Penn is clear: To form linkages between the disparate groups concerned with women's health and safety. In calling Summit participants to action, Robinson reminded the audience of what most already knew: that "women's access to basic health care the world over continues to be dismally low....Factors such as discrimination, stigma, lack of resources to pay for medicine and treatment, the inability to leave home to travel to clinics, violence against women and insensitivity to the social and economic barriers women face all contribute to the inescapable fact that millions of women are dying unnecessarily and are doing so on our watch."