Tag: health

Part II on the AIDS Crisis and Learning from History: Lessons from South Africa

In my last post, I profiled the Origins of AIDS, Jacques Pépin’s masterful study of how the virus that causes AIDS in humans originated in chimps and then jumped to humans and later took off as a result of a complex series of events involving local populations uprooted from traditional practices, the spread of prostitution, and widespread use of injections to fight infectious diseases, among other factors (see Donald McNeil’s compact summary review in the Times).
If Pépin’s book is of a scholar/detective sifting and sorting evidence to advance an argument, Geffen’s book represents the history if somewhat impersonal memoir of the experienced social pugilist. His efforts remind the world of the achievements of the Treatment Action Campaign (TAC), the South African AIDS advocacy campaign that challenged the government of Thabo Mbeki to provide antiretroviral  (ARV) therapy to those suffering from AIDS.

Geffen is one of TAC’s longtime leaders, and this book chronicles TAC’s clashes with both the South African government and a series of quacks and denialists who sought to promote anti-scientific remedies that likely contributed to the deaths of thousands of those suffering from HIV.

Geffen casts Mbeki (and his health minister) as villains in the struggle to extend treatment to those with HIV. For those familiar with the work of Nicoli Nattrass, William Forbath, the political cartoons of Zapiro, and others, Mbeki’s indulgence of AIDS denialism rings both true and familiar. 
Alongside retellings of the legal wrangling by TAC with the Mbeki government and the quacks and hucksters, Geffen peppers the narrative with stories of people who took the their advice rather than the guidance of the medical community. The examples of failed and ultimately fatal vitamin and garlic treatments are sober reminders of the price paid by so many. 
Geffen’s last chapter seeks to understand how it was possible that the African National Congress government, the movement of liberation from apartheid, could sully its legacy by embracing AIDS denialism. Here, Geffen engages a debate taken up in Evan Lieberman’s important book Boundaries of Contagion: “Why have some governments responded to AIDS more quickly and more broadly than others?” Geffen’s asks a slightly different question: “Why did Mbeki’s views on AIDS prevail for a while?”
Geffen writes: 

As president of the ANC and by far its most powerful member, Mbeki was able to impress his personal positions on the organisation. Despite an essentially democratic structure – branches and sectors elect their leaders, who in turn elect the organisation’s leadership at provincial and national level – the ANC has much within its culture that is anti-democratic and renders it vulnerable to and easily manipulated by the personal views of its strongest leaders (p. 193).

This argument, essentially about Mbeki’s leadership, is contingent upon the ANC exercising significant, largely unchecked, power over the country’s direction. As Geffen describes, the ANC possessed such status:

 The ANC together with its allies liberated South Africa from apartheid. It is recognized and admired as the liberator by about two-thirds of the voting population. This enables it to exert a powerful hegemony over South African society (p. 194). 

By appeals to African nationalism, Mbeki and his allies were able to stave off vigorous contestation from AIDS advocates for several years. Though TAC was ultimately able through the court system to push the South African government to change direction, the damage was done with at least two studies estimating that 330,000 plus deaths could have been averted with different policy.
This explanation – emphasizing the leadership role of Mbeki himself and the dominance of the ANC – fits my own understanding of the South African case as well as the Ugandan case where President Museveni took a much more aggressive stance in addressing the AIDS crisis.
Here, Geffen’s book intersects with the Lieberman book mentioned above. The recent issue of Perspectives on Politics features three (!) reviews on Lieberman’s book by Macartan Humphries, Eduardo Gomez, and Daniel Posner. While Geffen’s book is obviously limited to a single case and represents the work of an activist rather than academic, I found his answer more persuasive than the account, at least of the South African case, featured in Lieberman’s book. 
Through mixed methods including sophisticated econometric analysis, Lieberman attempts to show that the fluidity of ethnic boundaries explains the reason why some countries addressed AIDS more than others. Where boundaries are rigid, groups less affected fail to support policies to help out others, as they see themselves less at risk and those communities disproportionately affected by the AIDS crisis fail to mobilize, given their marginalized status. Where ethnic boundaries are weaker, there is a greater sense of shared fates.
Here, I share with Humphries and Gomez some of the concerns about Lieberman’s treatment of key cases and rival explanations. Humphries writes:

But South Africa remains puzzling. One would expect that if there were any place where the effects Lieberman describes would not be determinative, it would be in a case in which the affected group was both a large majority and in control of policymaking (pp. 875-876).

Gomez echoes this view: 

While he provides evidence showing that state capacity and the presence of NGOs is insufficient for predicting policy responses, it is hard to say the same for political leadership. The dismissal of AIDS leadership fell on President Nelson Mandela’s avoidance of the issue in South Africa, Thabo Mbeki’s interest in AIDS prior to election, and then his avoidance of it once in office, notwithstanding ongoing political support. In Brazil, Lieberman claims that aggressive policies predated Presidents Fernando Henrique Cardoso’s and Luiz Inácio Lula da Silva’s political leadership. Yet this is factually incorrect. Prior to Cardoso’s and the World Bank’s loans in 1993, there was no aggressive AIDS program. Thus, leadership under Cardoso, at the presidential and bureaucratic level, was important for reform (p. 878). 

In Lieberman’s view, leadership is unsatisfying because: “The relationship between cause and effect is so close that they are almost indistinguishable” (p. 19). However, one can identify differences in state structures where personal rule is possible. As Robert Jackson and Carl Rosberg argued in their classic article “Personal Rule: Theory and Practice in Africa,” many newly independent African states lacked institutionalized checks on individual leaders. While that portrait has started to change, it is still a recognizable feature in many African countries. Though South Africa possesses more of the societal and institutional checks than the rest of the continent – an independent judiciary, a free press, and a vigorous civil society – the ANC’s legacy as liberator and Mbeki’s privileged position within the party gave him significant scope to pursue an idiosyncratic agenda for several years.
While social scientists tend to dislike individual level explanations in favor of more domestic structural and international systems level explanations, one cannot understand critical cases like South Africa without bringing in agency and leadership. For that matter, we can’t understand PEPFAR without acknowledging the role of President Bush and his personal interest in the problem. Here, I’m reminded of the piece by Dan Byman and Ken Pollack in a 2001 issue of International Security, “‘Let us now praise great men: bringing the statesmen back in.” The challenge is to recognize the conditions under which leaders may exercise agency. The structural impediments  to action vary by country and circumstance. Sadly, in these tough economic times, the scope for more aggressive efforts to address the AIDS crisis appears much more circumscribed than it was just a few years ago.
Leaving this more theoretical social science question aside, Geffen’s book supports the notion that the Mbeki government did the wrong thing when it could and should have done something different. It is heartening that the Jacob Zuma government did an about-face on AIDS and has dramatically changed course to extend ARV therapy, support male circumcision, and enacted a host of other measures to treat and contain the epidemic.

Learning from Histories of the AIDS Crisis

What can we learn from histories of the AIDS crisis? Jacques Pépin’s The Origins of AIDS and Nathan Geffen’s Debunking Delusions: The Inside Story of the Treatment Action Campaign are two important contributions to our understanding of a disease that has now claimed nearly thirty million lives.

In different ways, both books raise interesting questions about what we can learn from history about causal mechanisms and wider sets of issues. In this two-part blog post, I’ll talk about each book and a recent set of review essays in Perspectives on Politics on Evan Lieberman’s important 2009 book Boundaries of Contagion: How Ethnic Politics Have Shaped Government Responses to AIDS.

Pépin, a Canadian medical doctor with a specialty in African sleeping sickness, has written a compact yet magisterial book that traces how the virus that causes AIDS leapt from chimpanzees to humans and then became a generalized epidemic in Africa that radiated around the world.

Pépin asks and answers a number of important questions in the book to weave a complex narrative of the worst health crisis since the Black Death. Could animals other than chimpanzees been the cause of transmission of HIV? (No. A hunter likely came in contact with chimp blood and picked up the disease and passed it on.) When and where, to the best of our knowledge did HIV originate? (Much earlier than we thought, perhaps as early as the 1920s and probably in central Africa in or near present day DRC). What role did colonial governments play in dislocating rural African societies and fostering the growth of male-dominated urban centers susceptible to prostitution? (By creating towns where only African men could legally live or by uprooting men to work on the railroads or the mines, the colonial powers disrupted rural populations and left large numbers of men without families and more likely to procure the services of the “oldest trade”). How did colonial era medical interventions to protect against other diseases like yaws and syphilis likely engender the spread of HIV? (Injectable drugs helped reduce the burden of infectious disease but poorly cleaned equipment likely helped spread HIV more widely). How did AIDS likely spread from Africa to and throughout the Americas? (One of 4,500 Haitian teachers in the Congo likely acquired the virus and brought it home where it became amplified through sexual tourism from the United States and the trade in blood which both spread the virus to hemophiliacs but also back to blood donors through efforts to separate out plasma).

As a political scientist, I found it fascinating how Pépin explicitly addressed alternative explanations for different facets of the argument. Even as Pépin sought to answer questions about AIDS, I learned a great deal about colonial era health practices, key protagonists in the fights against yaws and sleeping sickness, among other diseases. At each step, Pépin sought to engage rival explanations, “Could it have been this?”

At the same time, he consistently assembled a variety of evidence including colonial era statistics on trends in treatment of infectious diseases to sophisticated genetic evidence dating the origins of particular varieties of HIV with a margin of error.

In terms of policy and the present day, I was especially troubled how even well intended interventions to deal with other public health problems likely helped set the stage for the spread of HIV. This observation made me wonder how modern practices intended to enhance health and save lives (like the widespread use of antibiotics in animal feed) may create unanticipated consequences of grave proportions later on (such as drug resistance).

Even as AIDS continues to cast a large shadow over global health efforts, I wonder about our readiness for the next crisis and the leap of infection from animals to humans that proves both especially transmissible and deadly (or in light of the reports of manmade bird flu, from the lab to humans). Just this week, the Washington Post ran a story on the CDC’s efforts to test confiscated African bush meat for potentially lethal pathogens. The budget of this program: $59,740.

While I can’t say whether or not this amount of money is enough, I am worried that health agencies are being called upon to do more with less, in some cases much less. With the WHO having experienced unprecedented budget cuts in 2011 (nearly $1bn or almost 20% of its biennial budget) and the CDC having significant cuts of its own ($740mn or nearly 11% of its budget was cut between FY2010 and FY2011, are we becoming less capable in this time of economic crisis, even as our global health needs have grown?

In the next post, I’ll focus more on Geffen’s book and understanding the role of leadership in national efforts to address HIV/AIDS.

An AIDS-Free Generation?

Three weeks ago, Hillary Clinton gave a speech at the National Institutes of Health suggesting that because of recent advances in scientific understanding we could finally envision an AIDS-free generation. Wow, fantastic, the beginning of the end! Could it be?

A week ago, the Global Fund to Fight AIDS, TB, and Malaria announced that because of insufficient donor funding, it was canceling its next funding round for new projects and that it would likely struggle to maintain some of its existing commitments. On the Huffington Post, Jeffrey Sachs groused that President Obama hadn’t done enough to defend the Global Fund’s budget.*

Two nights ago, an optimistic Bono was on the Daily Show talking up the idea of an AIDS-Free Generation. With media accounts of the Global Fund in trouble, something does not compute. What is going on?

Yesterday, December 1, was World AIDS Day, and if you tuned in to the live webcast of the ONE Campaign event on YouTube like I did, you witnessed not one but three U.S. presidents – Obama, Bush the younger, and Clinton (plus Bono, Alicia Keys, and Sanjay Gupta!) take part in an event meant to celebrate and defend the role of the United States in the incredible scale-up of AIDS treatment services over the last eight years. President Bush was beamed in by telecast from Tanzania where he and the Tanzanian President made the case that PEPFAR, President Bush’s signature AIDS program (and the single most important positive legacy of his campaign), was a remarkable success.

President Bush had a terse warning for those considering gutting foreign aid spending:.

I understand that we are in tight economic times. The wealthy nations are going through budgetary struggles… There is nothing more effective than PEPFAR…. The number of people who live today as a result of PEPFAR is staggering. There is no greater priority. And this is something our American citizens must understand. And  our government must understand. There is no greater priority than living out the admonition to whom much is given much is required. We are blessed nation the United States of America. And I believe we are required to support effective programs that save lives.

President Obama followed his remarks by pledging to increase the number of people on treatment in the developing world from the existing target of 4 million to 6 million by 2013. Again, he talked about how we can finally envision an AIDS-free generation, that the combined efforts to employ male circumcision, prevention of mother to child transmission of AIDS, and early detection and treatment of AIDS could, along with other policies, ensure that the next generation is AIDS-free.

Now, at this point, the audience is hooting and clapping, as any dutiful audience is bound to when President Obama at his oratorical best. But, in my classroom where we were streaming the event live, there were a few titters and grumblings. Where is the money going to come from?

We know that the Obama budget for foreign aid has many detractors in Congress, and while global health spending is only subject to a modest trim in the House version, it would go down nonetheless. How do you propose to put 2 million more people on treatment when money is going down?

It was this kind of mismatch between rhetoric and reality that got health policy journalist-think tanker Laurie Garrett worked up in a pointed blog post:

It is time that everybody engaged in this ill-defined mission we call “global health” – including advocates for expanded access to HIV treatment – wake up to reality and cast off the old course entirely. The time is overdue for fundamentally new ways of thinking about what is meant by the phrase “global health,” how HIV fits into that picture, and most urgently how the overall mission is to be financed at proper scale, equity and sufficiently ensured for the long haul.

The UNAIDS Zero Campaign and Secretary Hillary Clinton’s AIDS-Free Generation calls are excellent goals. But reality dictates that the strategies used to attain those goals, and the tactics deployed both in the field and directed to donors must change radically and immediately.

Now, I’ve not had a chance to do the detailed analysis of the President’s plan, but on NPR on the way to the airport, the basic story that I heard was the President aims to do this through existing funds and extracting efficiencies in the program, by lowering drug costs further and by cutting the full costs of treatment, from procurement to delivery. Here, I want to be sympathetic to what the President is trying to do, but at this point, I’m not keen on the man overpromising and then not being able to extract the necessary resources from Congress.

I take it this event was a marker to try to defend the Administration’s spending on AIDS, by bringing the full political heft of three presidents, including a Republican, to bear. However, the times being as they are, speeches that talk about preventing the oceans from rising or talking about an AIDS-free generation just don’t quite do it for me any more. The devil is in the details and the politics.

* (As an aside, I tweeted back and forth with Sachs as Obama’s budget for 2012 is actually larger than the one that was requested last year. The real trouble is that the U.S. had a temporary lull in disbursements last year to the Global Fund due to new Congressional rules and the fact that countries like Spain and Italy are delinquent with their pledges or no longer contributing. In terms of Global Fund finances, the news about canceling the next commitment period may be a little over the top. To be fair, the Global Fund still plans to disburse $10 billion between 2011-2013.)


Safeguarding medical workers in hostilities

Yesterday the ICRC released a report on the very scary and depressing trend of attacks on medical workers in situations of armed conflict and civil disturbances:

According to Dr Robin Coupland, who led the research carried out in 16 countries across the globe, millions could be spared if the delivery of health care were more widely respected. “The most shocking finding is that people die in large numbers not because they are direct victims of a roadside bomb or a shooting,” he said. “They die because the ambulance does not get there in time, because health-care personnel are prevented from doing their work, because hospitals are themselves targets of attacks or simply because the environment is too dangerous for effective health care to be delivered.”

This makes for some pretty grim and reading.

Yet the evidence is clear – whether it is the targeting of medical workers in Libya, the targeting of a hospital in Afghanistan by the Taliban, or the unwarranted persecution of doctors in Bahrain. (A problem that Dan Nexon highlighted earlier this year here at the Duck.)  Even the allegation that the CIA found Osama bin Laden using a vaccination program puts medical workers and vaccination teams at risk – a potential disaster for global health.

(Aisde: Most, if not all of these issues, are being followed by Christopher Albon at his excellent blog, Conflict Health. Go read it. Read it now!)

The neutrality of medical staff in all circumstances is a core tenant of the laws of war, and some of its oldest codified principles. There is, quite simply, no excuse for harming someone who is engages in these tasks. This was the genius of the 1864 Geneva Convention:

Article 1. Ambulances and military hospitals shall be recognized as neutral, and as such, protected and respected by the belligerents as long as they accommodate wounded and sick.
Neutrality shall end if the said ambulances or hospitals should be held by a military force.
Art. 2. Hospital and ambulance personnel, including the quarter-master’s staff, the medical, administrative and transport services, and the chaplains, shall have the benefit of the same neutrality when on duty, and while there remain any wounded to be brought in or assisted.

These principles continues today as is clear in the First Geneva Convention of 1949. At the risk of being long-winded:

Art 15. At all times, and particularly after an engagement, Parties to the conflict shall, without delay, take all possible measures to search for and collect the wounded and sick, to protect them against pillage and ill-treatment, to ensure their adequate care, and to search for the dead and prevent their being despoiled.
Art. 19. Fixed establishments and mobile medical units of the Medical Service may in no circumstances be attacked, but shall at all times be respected and protected by the Parties to the conflict. Should they fall into the hands of the adverse Party, their personnel shall be free to pursue their duties, as long as the capturing Power has not itself ensured the necessary care of the wounded and sick found in such establishments and units.
The responsible authorities shall ensure that the said medical establishments and units are, as far as possible, situated in such a manner that attacks against military objectives cannot imperil their safety.
Art. 20. Hospital ships entitled to the protection of the Geneva Convention for the Amelioration of the Condition of Wounded, Sick and Shipwrecked Members of Armed Forces at Sea of 12 August 1949, shall not be attacked from the land.
Art. 21. The protection to which fixed establishments and mobile medical units of the Medical Service are entitled shall not cease unless they are used to commit, outside their humanitarian duties, acts harmful to the enemy. Protection may, however, cease only after a due warning has been given, naming, in all appropriate cases, a reasonable time limit, and after such warning has remained unheeded.

The idea behind this is that someone who is seriously injured is hors de combat – in other words, out of the fight, and can no pose a military threat. Allowing someone’s wounds to fester or get worse serves no military purpose once they are hors de combat; it only causes what is normally termed unnecessary suffering. (This is the same principle that bans poisoned weapons – there is no need to uselessly aggravate an injury on someone who is seriously wounded.) The individuals who treat these injured combatants (and civilians) of all sides must therefore be protected from attack. This is why they are allowed to wear the Red Cross/Red Crescent/Red Crystal symbols – it identifies them as neutral medical workers and helps to expedite the process of recovery and treatment. (Abusing these symbols, such as using them as a ruse to conduct an armed attack, is a grave breach of the Geneva Conventions.)

Certainly, there is more law I could cite here. But the main point is that the ICRC is absolutely correct to highlight this as a growing problem.


Why Isn’t Access to Pain Medicine a Global Public Health Priority?

The more I think about it, the more atrocious it is that a three year old burn victim in Pakistan or Libya cannot automatically access morphine.

Imagine being such a child’s parent, watching her suffer without pain relief. Imagine being a “collateral damage” victim undergoing surgery for shrapnel removal without anesthetic. Or imagine being an earthquake survivor like the Haitian 10-year-old above, having your mangled limb amputated and then trying to recover with no means to manage your pain.

Recently I spent some time talking to Jason Nickerson, a PhD candidate in population health at the University of Ottawa with a background in anesthesiology and years of field experience in Ghana. That conversation was peppered with horrific anecdotes from his days in Africa: watching children undergo surgery without morphine, watching trauma victims of routine road accidents dying in agony from their untreatable injuries.

This is a simply grievous situation, particularly because it’s so preventable. Yet until recently, I had always imagined that the major travesty in such cases was the absence of rehabilitative care – 60 Minutes’ expose of the Global Medical Relief Fund a few weeks back, for example, emphasized inequities in orthopedic or reconstructive surgery for child trauma victims in developing countries, but didn’t mention the simple fact that these children also lack basic anesthesia to cope with their trauma – even when undergoing surgery.

Since I’m writing a book about why some social conditions get constructed as global policy problems and others don’t, I’m primed to wonder why this issue has so little traction on the global agenda, why it’s not front and center in more people’s understanding of global public health. Based on my research about global agenda-setting dynamics, I have two answers and one policy recommendation for the campaign:

Explanations: Issue Complexity and UN Complacence. These two factors are strongly correlated with how likely it is that a global social problem will get attention by global policymakers. They’re also correlated with each other.

1) “The Complexity of the Problem.” Typically, neglected global social problems have garnered attention from policy “gatekeepers” (like donors or powerful NGOs and UN agencies) when they have been repackaged as significant, solvable problems by issue entrepreneurs. It’s easier to do that with some problems than it is with others. In their landmark book on advocacy campaigns, Margaret Keck and Kathryn Sikkink argue that problems with a short causal chain to a specific perpetrator, whose behavior (if changed) can quickly solve the problem, are better advocacy candidates than problems whose sources are complex or “irredeemably structural.” And unfortunately, inequities in pain medicine are the result of myriad factors: culture, bureaucratic practice in developing countries, international governance of the drug trade, antiquated preferential trade agreements. These inequities are solvable through a series of steps that could easily be taken with appropriate political will. But because the steps need to occur in tandem, it becomes harder for an advocacy movement to package the solution as a single concrete policy proposal. [Though they’re trying.]

2) Inattention From Advocacy “Gatekeepers.” Clifford Bob has noted that the most important nodes in transnational issue networks are the organizations most visibly associated with the relevant issue area (Amnesty International plays this role for the human rights issue area, Greenpeace for the environment, the International Committee for the Red Cross for humanitarian affairs, etc). My work on weapons norms confirms Cliff’s insight: such organizations can propel an issue to the global stage simply by paying attention to it; or they can consign it to the margins of the issue area by ignoring it. In the global health arena, the key gatekeeper is the World Health Organization. WHO has nominally “adopted” the issue of pain relief, with a press release and a “Global Day Against Pain.” But unlike its vast efforts in the area of HIV-AIDS, it has not thrown resources behind this issue. If it did – if a donor like the US earmarked $10 million toward pain relief advocacy and the WHO exercised its authority to initiate a Framework Convention, for example – the issue could take off on the global agenda and important changes could result.

So how to get donors to make this happen? By simplifying the issue – focusing on just a piece of it – and let that piece be the one that resonates with the widest swath of citizens in donor countries.

Recommendation: Shift the Frame. Currently, the global pain relief issue has been framed around access for terminally ill patients. Much of the noise is coming from the palliative care health community. Many of the anecdotes provided in news coverage refer to cancer and HIV-AIDS victims. The WHO’s engagement with the issue is directly related to its work on cancer pain relief. Certainly this is a huge segment of the population who would stand to benefit from wider availability of pain meds. Suffering from cancer is (I have heard) no less painful than suffering from lacerations or burns. And the ability to die with dignity instead of in agonizing pain is certainly an important human right and a noble cause. But as a cause that resonates with a mass audience and policymakers (in a donor culture where the right to die itself remains a controversial topic) I suspect this angle is going to be less resonant than images of child burn and wound victims – experiences most people can relate to. Bottom line: the movement needs to focus on the absence of anesthetic for surgery and trauma care in the developing world, using landmine and road traffic accident victims as poster children, and move away from arguments about palliative care… for now.

This argument may seem heartless. But note that this type of strategy has been used by most successful advocacy campaigns of the past. Complex issues can be and have been turned into successful campaigns (think of efforts to stop “violence against women” and “global poverty”). But the campaigners that do so frame their issues not necessarily to reflect the complete, “irredeemably structural” picture but so as to resonate with their target audience and attract the greatest sympathy possible.

Landmines campaigners, for example, didn’t focus on the complete picture of landmines – how in some cases they’re probably more humane than the alternatives, or how the biggest victims of landmines are military age men. Instead they stressed the collateral damage of mines to children and women because this would resonate with publics and policymakers. The child soldiers campaign didn’t focus on the complexity of the child soldiers issue – how these children are some of the least vulnerable in conflict zones, and often choose to join armed groups as a rational response to poverty, family violence, or political engagement. Instead they focused on the most heinous cases of child abduction into groups and used this frame to galvanize a movement. In both cases, their efforts resulted in a treaty.

Once analgesics are more generally available in the global south, palliative care victims will also benefit. To make that happen however, history suggests spot-lighting trauma victims rather than chronic, end-of-life pain sufferers could make for a more high-profile campaign.

Commenters, please leave your ideas on how global health advocates can campaign more effectively to draw resources toward solving this pressing global social problem.

[cross-posted at Lawyers, Guns and Money]


The Ethics of State Involvement in Women’s Health

I have been fortunate to be a part of a number of interesting conversations over the last few weeks, and am currently attending the conference linked above, hosted by the Levan Institute for Humanities and Ethics, the University of Southern California Global Health Institute, and the Center for International Studies at the University of Southern California. Conversations are centering around global norms and international agreements on women’s health, health aid, human trafficking, economic empowerment, violence and war, and medicine distribution. These conversations are extremely interesting to me, and just outside of my research agenda enough that I’m learning a lot without having preconceived notions of what I should be thinking on particular topics.

When I was invited to be a part of this conference, I decided to revive my interest in legal research and discrimination law, and pair that with my interest in gender in global politics. My presentation discussed the differential impacts of different grounds on which abortion is legalized in providing the expected women’s health benefits from legalization. A couple of themes in my paper have come up in other panels, and lead me to be more generally interested in researching the role of taboo in the protection of rights and the provision of goods and services to women. I’ll provide a skeleton of what I’m thinking about …

When abortion is illegal, illegal abortions take place frequently. The complication rate for illegal abortions is much higher than for legal abortion, where fully 1% of people who have illegal abortions die from complications and almost 5% have permanent health complications, while legal abortion is actually less likely to cause fatalities than childbirth. Worldwide, almost 80000 women die every year from complications from illegal abortions, and abortion-related deaths drop around 90% in the first five years of legality.
Fully half of abortions that take place every year are illegal and most of those take place places where abortion is illegal.

I couldn’t help but wonder if there is more to it. While legalizing abortions is necessary to decreasing the death rate from unsafe abortions, it is not sufficient. Particularly, I approached it by thinking about the grounds on which abortion is legalized.

Whether abortion is made legal by a court case (as in the United States) or by legislative process, a “grounds” on which abortion is legal almost always accompanies the jurisprudence or legislation. For example, in the United States, privacy is the grounds for abortion legality. Other places, involuntariness of the pregnancy, out-of-wedlock pregnancy, “maternal” health, and other grounds maintain the general taboo against abortion but make exceptions for certain circumstances understood as extreme. Other grounds for the legality of abortion eschew the taboo, characterizing abortion as generally acceptable behavior rather than acceptable only in extreme circumstances. These grounds include women’s rights and women’s labor arguments.

It is easy to say that the grounds don’t matter, abortion is legal or it is not. But practically, that’s not true at the most basic level because the grounds impact to whom abortions are available and when. Still, the grounds also affect availability in other ways …both in terms of the ease of obtaining abortions and the permissiveness (or lack thereof) of social norms and social culture surrounding the obtaining of abortions.

In theory, the “taboo-maintaining” grounds for legalizing abortion relegate women’s abortions specifically and their bodies generally to the private sphere of social and political life, a reification of the personal/political divide that feminists have always found both insidious and materially harmful to women. The division of the political and social world into ‘public’ and ‘private’ marginalizes those interests which are in private places, like inside the home, or inside their bodies. When issues fall on the “private” side of the public/private dichotomy, they are considered rights of individual bodies, which are often negative rights and even more often subject to situational enforcement.

On the other hand, grounds for the legality of abortion that remove it from the private sphere argue that it is a gender-based right, either in terms of equal protection of the laws or in terms of inequities in labor performed or the labor market. In countries where these are the grounds, the interconnections in women’s inequality between forced sex, economic deprivation, and reproduction are recognized as a matter of law.

In the early results of my study on these issues, controlling for poverty and the degree of abortion legality, the grounds on which abortion is legal are a significant predictor of the marginal effects of legality on women’s health as a result of abortion – abortions are safer places where the grounds lift the abortion taboo in addition to legalizing abortion. This is significant at the .001 level in a number of different coding variations.

The question of the “abortion taboo” has come up elsewhere today, and I have spent most of the morning thinking about the potentially fruitful relationship between feminist theorizing in IR/comparative politics and the study of (sexual and gendered) stigma and taboo in IR. What are the functional impacts of taboos? How are they gender-differential? And is a taboo a norm like we talk about in the literature on norms, norm diffusion, and norm entrepreneurs in IR? Or do we need some other framework through which to evaluate the idea of a stigma or taboo and its influence in global political and social relations?


“Freedom Fries” A Threat to National Security

When I make the connection between health and national security in my classes, we usually talk about pandemics or bio-warfare. But check this out: a new study from the Army Times tells us that unhealthy diets also drastically reduce America’s military readiness.

Turns out 35% of young Americans between the ages of 18-24 are unfit to serve in the military because they’re too fat, up from 6% 20 years ago. Noah Schactman has more.

Is this any surprise, really?

Perhaps the US government should declare a global war on cholesterol in the name of national security. Only instead of using unmanned drones to target those freedom-hating global corporations who market high-fat meals to our kids, perhaps DHS could just team up with USDA to get fresh fruits and vegetables into our public schools, and pop / candy machines (and fast-food propaganda) out. Updating the USDA’s definition of “junk food” would be a start. Clearly, the safety of our shores depends on it!


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