Geographies of Women's Health

Place, Diversity and Difference

Nancy Davis Lewis, Isabel Dyck, Sara McLafferty

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781134562480
• Edition: 1
• Topic: Social Sciences
• Subtopic: Gender Studies
• Index: Social Sciences

This international collection explores the relationships between society, place, gender and health, and how these play out in different parts of the world. The chapters work together in examining the complex layering of social, economic and political relations that frame women's health. The authors demonstrate that women's health needs to be understood 'in place' if gains are to be made in improving women's health and health care.

1 Why Geographies of Women’s Health?

Isabel Dyck, Nancy Davis Lewis, and Sara McLafferty

Introduction

The last decade has seen an escalating interest in understanding the health of women. As women’s health has been explored, the limits of biomedical approaches in understanding health and illness have become evident. Reliance on biological and physiological explanation of women’s health and illness is challenged by documentation of the ways in which women’s location in complex social, political, and economic relations affects the content and meaning of their lives, including their experience of health and sense of well-being. Gender is shown to be a major axis of difference that affects health status, while class, “race,” and nationality are also interrelated in complex ways with health inequalities. Social science is now commonly, but not universally, acknowledged as an essential ingredient in understanding women’s health, one that must take into account the various dimensions of “context” in which women live.

Although social science scholarship concerned with women’s health has not always employed feminist theory, feminist inquiry has made important contributions in two main ways. First, through centering women’s experiences and locating these experiences in wider social relations and political economies, conventional ways of conceptualizing women’s health issues have been extended. The organization of gender relations and the gendering of activities situate women in conditions conducive to health and ill-health. Women’s working conditions in and outside the home, their position in the household, their reproductive roles and associated sexual practices all contribute to their experience of health. Second, feminist scholarship has been influential in prescribing research methods that are appropriate for investigating gendered social relations and their impact on where and how women live. Research based in the successive waves of feminism has challenged woman as a unitary concept. In addition, the inadequacy of Western feminism’s concepts in explaining women’s lives in developing countries has been exposed, and ways in which research can be ethically conducted along feminist principles with emancipatory aims has been debated. Together, these contributions have opened up ways of exploring women’s health that emphasize the importance of the interconnections between the biological, psychological, social, cultural, economic, and political dimensions of health and illness.

Social science scholarship on women’s health also grows out of pragmatic concerns about the impacts for women of global and regional transformations. What women do and the environments in which they live are changing. The opportunities and resources for improving health are being transformed in the context of social, economic, and technological processes which affect the types of work women and men engage in and the organization of reproduction. In the developing world, economic recession, structural adjustment, environmental deterioration, and ethnic strife have had special ramifications for the health – or ill-health – of women. Similar concerns are emerging in Eastern Europe and the former Soviet Union, where the health impacts of decades of environmental degradation are only now being revealed. Around the globe, women’s increasing participation in the paid labor force, widening class divisions, and restructuring of health and social services are reshaping women’s health and access to health care. In addition, the international financial community’s belated recognition of women’s role in economic development has increased the burdens on women, responsible now not only for their own health, but for that of their families, the environment – and the economy.

Until recently the contribution of geography has been largely absent in these investigations of women’s health. With this volume, in which many but not all authors are geographers, we begin to fill that lacuna. We explore a wide range of issues concerning women’s health, and suggest ways in which geographic inquiry can further our understanding of the health of women. As in other social science disciplines, we move away from a medical focus to a broader understanding of health, locating the discussion within political and economic processes and social change. How such processes play out in particular places brings a distinct geography to women’s health issues and to their health care, whether as consumers or providers. How women’s health is defined and responded to, what conditions produce health or ill-health, and what resources are available to women as they manage their own or their families’ health and illness are all shaped within particular polities, economies, and cultural discourses about gender.

The authors of the chapters employ both qualitative and quantitative methodologies in their inquiries and the approaches taken are diverse and representative of the many lenses now being employed in understanding the health of women. Running through many of the contributions is the inclusion of women’s own perspectives of health and illness and ways of managing health. These bring further nuances to the depiction and understanding of the complex interactions between place, gender, and health. The chapters suggest the importance of both traditional research approaches and women-centered methods in understanding women’s health. What is significant in these accounts is that women are rarely best viewed as “victims,” but should be seen as women exploring and using active strategies in managing health and illness and accessing both formal and informal health care systems. Together the chapters begin to tease out relationships between society, place, gender, and health, and how these play out in different parts of the world. They reflect the changing concerns of inquiry in the field of women’s health; chapter topics take us beyond the confines of medical definitions, medical sites, and biomedical provinces of knowledge to other areas, both conceptually and spatially beyond the clinic.

Research on Women’s Health

In the biomedical research arena, until a decade and a half ago, the health of women had been largely ignored. A reason given was that white males were a convenient research norm. Kreiger and Fee (1994), however, argued that the lack of research on white women, and men and women in non-white racial and ethnic groups was not for convenience, but rather that these omissions must be read as evidence of a logic of difference. From a global perspective, we do not know to what extent the majority of research findings, which influence health strategies around the world, include the 90 percent of the global population not represented in these studies (Feacham et al. 1989). Greater research focus on lung cancer, perceived to be a male cancer, than on breast cancer was often cited as an example of this gender bias. Ironically, recent research findings suggest that a gene linked to the abnormal growth of lung cells is much more active in women than in men, and that nonsmoking females are three times more likely to develop lung cancer than nonsmoking males (Arnold and Eckstein 2000).

In the latter half of the 1980s, women’s health appeared on the political – and research – agenda. It was a decade in which groups, including many feminist organizations, exerted increasing pressure on policy makers to address women’s health. This resulted, on the biomedical front, in the creation of the Office for Research on Women’s Health and the Women’s Health Initiative in the United States. Federal, provincial, and territorial working groups were set up in Canada and a number of research centers for women’s health were set up in Australia and elsewhere. Thomas and Rigby in this volume discuss the EU’s European Women’s Health Project, an example of this heightened interest, and highlight the dissonance, attributed in large part to political pressures, between the survey as designed and the final product.

In the international arena, women’s health also took center stage. Women’s health was central to the debates at the International Conference on Population and Development in Cairo, September 1994. It was also a major component of the Platform for Action at the Fourth World Conference on Women in Beijing and a major theme at the concurrent NGO Forum on Women in Huairou, in September 1995. It continues to be central in follow-up activities. An important message from Beijing was that health is a human right and women’s rights are human rights. The understandable focus on maternal and child health and “safe motherhood” was expanded to include all aspects and stages of women’s lives and to encompass physical, mental, social, and economic health, or “safe womanhood” (Lewis et al. 1994). This increased interest in women’s health resulted in a plethora of meetings, publications, initiatives, and research agendas (Lewis 1998). Narrow, biomedically based models of women’s health are being replaced with broader socio-ecological models of health. These increasingly recognize the value of social science research (Caldwell 1993; Caldwell et al. 1990; Chen et al. 1993) and the contribution of transdisciplinary approaches (Bird and Rieker 1999; Rosenfield 1992; Social Science and Medicine 1992, 1996). Gender, however, had not always been explicitly incorporated into these frameworks (Caldwell and Caldwell 1994). Ruzek (1993) called for a social model of health that puts women’s health needs at the center of the analysis and focuses attention on the diversity of women’s health over the life-cycle.

Conceptualizing Women’s Health

A social model of health situates women’s and men’s health in particular social, economic, and political circumstances – varying over time and space. It emphasizes that the biological, although the site of acute and chronic disease symptoms or traumatic injury, must be closely related to social relations and processes in understanding why and how people are sick. Feminist analyses emphasize the influence of structured inequalities based on gender – but also those pertaining to class, “race,” sexual orientation, and age – on women’s health. Health status and experience are understood as gendered phenomena. Gender is not equated with “sex difference” in this framework of understanding. Rather it refers to the socially and culturally constructed meanings around biological sex which inform notions of femininity and masculinity and associated norms of behavior. Such meanings and related gender identities and performance are not fixed. They shift over time and vary across space, so that what constitutes being a woman or a man in a particular society is a negotiated position. Feminist scholarship has documented and theorized the subordination of women within webs of meaning about masculinity and femininity that are translated into the organization of polities and economies and attendant social life and health. Doyal (1995), for example, suggests that women experience both material discrimination and cultural devaluation that, respectively, affect their access to the resources necessary to maintaining a healthy life and threaten their emotional health. This holds, Doyal points out, despite the wide variation in women’s situations within their own societies and between countries. Drawing on international research, she shows that what women do as mothers, daughters, or wives, whether in domestic, waged, or unpaid community work, affects their health and how they manage health problems, sometimes detrimentally. Furthermore, attention to gender signals the importance of investigating the role played by women in care-giving, whether as professionals or family caregivers, and the further impact such care-giving may have on a woman’s own health. Health cannot be compartmentalized as a separate issue in women’s lives; rather it is integral to everyday life, its absence or presence closely linked to the organization of social relations at different geographical scales and an individual’s positioning in society.

Whether emphasis is placed on political economy, cultural and social change, or women’s agency in seeking to improve their health, where in the world women pursue their lives also matters to how they experience and manage health and illness. Cross-cultural variations are shown, for example, in life-cycle concerns, disease incidence, and dealing with threats to health (Whelehan et al. 1988). Health status and access to health care statistics also show inequalities between women throughout the world and within particular polities and economies. Yet gender, represented through a depiction of “the inseparability and co-mingling of their various tasks that tends to differentiate women’s lives from those of men” (Doyal 1995: 21), remains an important social determinant of health. In short, being a woman is associated with particular hazards to health. Following from this, Doyal advocates analyses of how the activities of women’s day-to-day lives impact on their health, taking into account material context, cultural constraints, and women’s lived experience. Being healthy, she suggests, goes beyond subjective well-being to being free from sustained constraints on achieving one’s potential and enjoying a satisfying life.

This conceptualization of health is similar to the approach of the World Health Organization (1986) and other holistic frameworks (e.g. Epp 1986) informing health promotion activities. These view health not merely as the absence of disease but as a resource for living – enabling people to cope with and change their physical, social, and economic environments in realizing their aspirations. Since the mid-1980s, increasing emphasis has been placed on the socio-environmental factors affecting health, culminating in a population health perspective which, however, has not gone without critique (see Hayes and Dunn 1998 for a review). The attendant politics of broader definitions of health also differ. Health promotion frameworks still tend to focus on individual change, despite recognizing the large part played by social determinants of health. Additionally, feminists, noting the inadequate articulation of gender in these frameworks of health, claim improvement of women’s health must be based on analyses that promote understanding of how intersections of gender with other axes of social difference construct and maintain health inequalities.

Geographers have been well positioned to explore the complex links between “environments” and health in this shift to holistic models of health, whether at the scale of geopolitical positioning or the local level of everyday life. In the midst of the process of reconceptualizing health, Canadian geographers noted the potential contribution of their discipline to the project of “achieving health for all” (Rosenberg et al. 1990). Since then, medical, social, and cultural geographers have explored the contribution of social theory to understanding health, health care, and disability issues, and in so doing created a “new” medical geography or “health geography.” Engaging with concepts of space and place in new and varied ways and working with a “cultural turn” throughout human geography, geographers have analyzed health, illness, and health care access as phenomena with intricate links between the “personal,” the local, and global processes. Calls to reinsert space and place in medical geography were accompanied with a reworking of these concepts. Place, rather than being seen simply as location with the concomitant understanding of space as a “container” of action, is theorized as a relational and dynamic concept (Jones and Moon 1993; Kearns 1993).

Incorporation of social theory in analyses also brought health geography closer to work in cognate areas. An emphasis on narrative and a focus on the body, as both corporeal and discursively inscribed, forged new spaces for inquiry (see for example, Dorn and Laws 1994; Kearns 1995, 1997). Experiential accounts, the interrogation of medical categories, and the spatial and discursive constitution of the “deviant” bodies of the physically or mentally ill are areas commanding recent attention. A special issue of Environment and Planning D: Society and Space (1997) and collected volumes concerned with illness and disability (Butler and Parr 1999; Kearns and Gesler 1998) signal an emerging concentration of work in the spirit of the “new” health geography. These collections included analyses of the specificities of women’s health and disability, although women’s health was slow to attract attention in geography.

Geography and Women’s Health

Somewhat later than other social scientists (Matthews 1995) geographers are adding their multiple voices to the exploration of women’s health concerns, employing both quantitative and qualitative methods and contributing from a number of different theoretical perspectives. In 1989 Pearson had claimed that medical geography was genderless and colorbli...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Contents
• List of illustrations
• Notes on contributors
• Acknowledgments
• 1. Why geographies of women’s health?
• Part I: Globalization, structural change, and political realignment: implications for women’s health
• Part II: Providing and gaining access to health care: local areas and networks
• Part III: Embodied health and illness, perceptions, and place
• Index