Wenxi Yu

Although published in the last century, Margaret Atwood’s 1985 dystopian and postcolonial novel, The Handmaid’s Tale, has, almost prophetically, pointed out today’s real-life issues related to infertility and women’s right to control their bodies regarding childbearing, birth control and abortion. In this blog I will focus on the issues of gender inequality and misogyny reflected in the novel and examine how women are ‘othered’ and how female misogyny is formed, so as to develop ideas for future women’s empowerment.

The novel depicts a fictitious world where women’s rights are severely restricted following the establishment of the Republic of Gilead, a highly patriarchal, totalitarian theonomic state (Attwood, 1985). Women no longer have the right to read, write or own property since they are expected to be men’s accessories. Significantly, fertile and ‘fallen’ women (eg, lesbians, single or unmarried mothers, women who have been married more than once, ‘heathens’, political dissidents, and scholars) are classified as ‘handmaids’ and enslaved to breed for the infertile elite, with their bodies being deemed a national resource.

Underlying the plot is a concept called ‘Otherness’, which enables us to comprehend how women are governed. The concept of ‘Other’ is generated during social identity construction (Zevallos, 2011). Social identities represent how individuals perceive themselves in relation to their group membership(s), and they separate the world into ‘us’ and ‘them’ through social categorisation (Tajfel, Turner, Austin & Worchel, 1979). Because no group can define itself as the One without simultaneously defining the Other as its opposite (Marcus, 2020), by establishing such binary opposite social categories (eg men versus women), a sense of belonging is generated (Hall, 1992), and the ‘them’ becomes the outsider that is distinct from the ‘us’.

Otherness and power

Social identities are not innate; they are developed within a social hierarchy in which some are deemed superior to others (Briedik, 2021). This is where power enters the picture, as the negotiation of these identities typically depends on the negotiation of power relationships (Zevallos, 2011), and the outcomes (eg, who is ‘them’) reflect power differentials between groups (Okolie, 2003).

According to Foucault (1979), power derives from knowledge, exploits knowledge, and reproduces knowledge to achieve its own goals. As Zevallos (2011) remarked, because of their command of discourse, social institutions (eg the law, the media, education and religion) are capable of wielding power through their portrayals of what is considered ‘normal’ and ‘Other’.

Hall (1992) describes discourse as generating a certain kind of knowledge about a topic through the use of a collection of statements (ie language). In the novel, Gilead subjugates and controls women through language, brainwashing and surveillance. Not only have words been obliterated from the women’s world, but they are also restricted by a coding language that reshapes their identities and confines their social relationships (‘Blessed be the fruit’; ‘May the Lord open’) (Howell, 2019). As a result, women’s self-identities are suppressed, and through constant verbal, psychological and physical abuse (Howell, 2019), what Foucault (1979) refers to as ‘docile bodies’ are produced.

Female misogyny behind the scenes

When first reading the novel, it appears that the term ‘double colonisation’, which refers to imperialism and male dominance over women (Ahmed, 2019), can accurately capture Gilead’s control over women. Nonetheless, with further examination, there appears to have been female-to-female competition under patriarchal and imperial control (Calvi, Rankin, Clauss & Byrd-Craven, 2020).

In addition to becoming appendages of men, women in Gilead are socially classed and must adhere to strict dress and behaviour standards, as illustrated in Figure 1. Such restrictive social norms can cause women of other classes to view handmaids as sinful (Williams, 2017) and develop an awareness of what Finigan (2011) refers to as misogyny, since they are educated to despise the handmaids.

Figure 1: Social classification of women in Gilead (Makenzie, n.d.)

Manne (2019) defines misogyny as contempt and sometimes hatred directed toward women. She argues that misogyny demonstrates how patriarchy and sexism manifest themselves in social relationships, with sexism serving as the ideology that sustains patriarchy and misogyny reinforcing its ideas. Einhorn’s article (2021) on how misogyny affects female-to-female relationships implies that women may internalise misogyny under patriarchy and maintain patriarchal power relationships and misogynistic ridicule through peer policing. Margaret Atwood’s famous quote is as follows: “Men are afraid that women will laugh at them. Women are afraid that men will kill them” (Atwood, 1985). This quote demonstrates how fear of male violence fuels female misogyny in a patriarchal society rife with class divisions and racism. Women supervise one another to protect themselves from the risks of male violence and peer noncompliance (Einhorn, 2021); as a result, women may dread one another.

Towards women’s empowerment

Despite being designated as Goal five of the Sustainable Development Goals launched by the United Nations (n.d.), achieving gender equality and female empowerment remains problematic in many parts of the world. For example, women are often blamed for a couple’s failure to conceive (Ombelet et al., 2008), despite the fact that male infertility accounts for about half of global childlessness cases (ranging from 20% in Sub-Saharan Africa to 70% in the Middle East) (Agarwal et al., 2015).

Meanwhile, when it comes to birth control and abortion, the right of women to maintain control over their own bodies is still being questioned in countries like the United States, the United Kingdom and Australia (Howell, 2019). Worse still, countries such as Poland, Iran and the majority of Latin America are enacting the world’s strictest abortion laws, forcing women to travel for abortions, use unsafe methods to terminate their own pregnancies or be forced to carry an unwanted pregnancy to term, even if their health is endangered (Fratti, 2018). El Salvador has one of the strictest abortion laws in the world, prohibiting women from having abortions under any circumstances, including to save their own lives, and those who have abortions or miscarry face prison sentences of up to 30 years (Januwalla, 2016).

Inspired by such reality, the ordeals endured by the Gilead women in the novel are as heinous as one might conceive. Women at all social levels are subject to control by their spouses, the Gilead government, and peer supervision. They are brainwashed into believing that such an oppressed society and their submissive positions and roles are normal. Women who are caught reading or writing will be punished by having a hand or finger removed “to find redemption”. Handmaids in particular are told by the government, men and even other women that a lifestyle of consistent ritualised rape, childbearing and physical and emotional abuse is all for “redeeming” themselves and working off their “sin”. If they refuse or attempt to evade their roles and “duty,” they face death, being forced to live and work in fields contaminated with poisonous chemicals until they die, or becoming a sex slave. If they have conducted abortions, whether before or after Gilead’s rise, they will be put to death.

As such, now that we are aware that both men and women make covert and overt attempts to control females in both the novel and reality, it is time to consider how to address otherness and misogyny towards women in order to help women take back their human rights.

One viable strategy offered by the novel is for men and women to share a common goal. The novel reflects Einhorn’s (2021) statements that when individuals are involved in a common struggle, friendship may develop and help people to overcome their otherness and unite.

However, a more critical question may be: ‘Are people aware or knowledgeable about the fact that something is problematic?’. As previously stated, individuals may have been indoctrinated with ideas that are ‘orthodox’ and thereby become unaware of the issues or take them for granted. For instance, Chinese people are commonly influenced by Confucianism, which instructs individuals to follow ‘traditional virtues’ and always submit to authority, which typically is the male figure and elders (Holroyd, 2003). Even in recent years, many ‘female virtue’ schools supporting male superiority and female inferiority and recruiting female students under the guise of ‘strengthening traditional Chinese virtue education’ still exist (BBC News, 2017). As such, it is difficult for people to change their mindset due to the early or even lifelong influence.

Nevertheless, perhaps only positive discourse is capable of defeating negative discourse. The #Metoo campaign exemplifies this, demonstrating how positive discourse can contribute to women’s empowerment and how common challenges and wishes can overcome differences. As being propagated via the media, the ‘MeToo’ slogan encouraged both female and male victims of sexual harassment to courageously speak out and fight for themselves, other victims and potential victims (France, 2017). As this quote by Vygotsky (1978) – “[a]ll the higher functions originate as actual relations between human individuals” – suggests, both human thought and purposeful behaviour are contextualised within and evolve from shared experiences and relationships. This means that sharing objectives with comparable others would help individuals develop a more optimistic outlook and raise the likelihood of people pursuing both individual and shared goals (Shteynberg and Galinsky, 2011).

Despite this, a real challenge in this could be that today’s technological developments on social media have also increased the amount of anti-feminist content available to people (Burgess et al., 2019). Popular YouTube videos and memes that dominate young people’s online habitats are now conveying concepts such as evil women controlling men’s lives and rape as a natural result of “depriving” men of sex (Murdoch, 2019). Given that the more misogynistic information individuals see, the less shocking it will be, with low-level sexism and sexual harassment still part of life for many women, radical misogyny is likely to become more acceptable to young people exposed to it online. The mainstream media’s speculation about whether #MeToo is a “witch hunt” and headlines about “henpecked spouses” snapping and murdering their lovers legitimise even more extreme beliefs (Bates, 2021; Mumford, 2018). Extremists celebrate this kind of “mainstream” content to make it a publicly acceptable discourse, thus making their misogyny ideas appear more reasonable (Bates, 2021).

The incel movement, which spreads an ideology of violent misogyny online, is an obvious case. The term “incel” is derived from the phrase “involuntary celibacy,” which was coined in the mid-1990s to refer to individuals who are not having sex but wish they were (Bates, 2021). The young woman who invented this term also founded a supportive mixed-sex online community for these lonely people yearning for love (Taylor, 2018). However, over time, this “friendly self-help community” evolved into a space for males who subscribe to an ideology defined by male supremacy and female subjugation to laud and encourage male violence (Louie, 2018; Bates, 2021). The advocates viewed themselves as permanent victims of a “female gynocracy,” claiming that sex is an intrinsic right of men and that rape and murder are only vengeances for a society that withholds sex from them (The Week, 2021). When feminists are described as a hate group bent on terrorising men, young males already anxious about societal expectations of tough, traditional masculinity can easily fall into the extremists’ clutches to portray men as the true oppressed victims within society and against feminist movements (Bates, 2021).

In addition to such spreading online hatred, the incel movement has also led to terrible real-world consequences. We know that numerous men, such as Jake Davison in the United Kingdom and Elliot Rodger and Alek Minassian in North America, have been radicalised by incel ideology before perpetrating mass murders (The Guardian, 2021; Louie, 2018). However, we cannot quantify the number of people exposed to such rhetoric and ideology prior to murdering women or the amount of harassment, sexual assault and rape committed against women in society due to incel ideology and other types of sexist and misogynist extremism (Bates, 2021).

In light of this, it is clear that the division of people, accentuated by anti-feminist and misogynist discourse spread via social media platforms, has made it more difficult to rally people together in support of women’s empowerment. Meanwhile, just as every coin has two sides, so does discourse. On the one hand, discourses such as “incel” can positively unite people with similar experiences or aspirations and generate a sense of connection, acceptance and comprehension. Nevertheless, such “positive” discourse could function negatively, sparking a perfect storm of rage, hate and a desire to harm others, further polarising people (Louie, 2018).

Concluding remarks

The Handmaid’s Tale has prompted analysis of issues beyond fertility, such as gender inequality and misogyny, which, as depicted in the novel, are serious real-world problems that require attention and resolution. Control over women begins with the assignment of social identities, and women can further be constrained into ‘docile bodies’ by power. The theory that the domination over women is completely patriarchal – and sometimes, imperial – is inaccurate; the role of internalised female misogyny in this cannot be overlooked.

Fortunately, when common challenges or goals arise, people may put their differences aside and work cooperatively for the greater good. Social institutions should take their responsibilities and use their power appropriately to guide the public and inspire a greater public awareness of the issues and need for women’s empowerment. At the same time, the negative influences posed by social media should also be considered and their potentially harmful effects minimised.

References

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Ana Gutierrez

Imagine yourself in the following scenario: you are in Mexico, an upper-middle-income country that is dealing with growing inequalities across the board. You are the owner of a restaurant that is economically buoyant and you have seven employees. Under Mexican law, all of them need to have some sort of medical insurance. You can either pay for the public sector Social Security insurance, which entitles your employees to a basic set of healthcare rights in a system that is overextended, underfunded and overcrowded, or you can pay for private insurance, for about the same amount of money, which will cover the same basic healthcare rights but your employees will be treated better and more quickly. What would you do?

The answer seems simple to me: with shorter waiting times and no complicated paperwork to complete, I would insure my employees with a private insurance company. The fact that this is allowed (and encouraged) by the Mexican government is a clear sign of the neo-liberal policies by which the country has been run for the past 30 years and a symbol of a struggling public healthcare system that at this moment leaves more than one-fifth of Mexico’s population unprotected (INSP 2020).

The system

First, it is necessary to understand how the Mexican healthcare system works. It has two major sectors, the public and the private. Within the public sector the insured or covered population can further be divided into two: people with Social Security, meaning people who work and are covered by one of the multiple state-owned programmes; and people who don’t have a job or work in the informal sector (56.2% of the population according to National Institute of Statistics and Geography (INEGI) in 2020), who are entitled to enroll themselves in the Secretariat of Health Popular Health Insurance programs. Then there is the private sector, which is made up of a heterogeneous group of hospitals, maternity wards, health clinics and private doctors, all of whom can be paid out of pocket or through private insurance (Gomez et al. 2011; Barraza-Lloréns et al. 2002).

Funding is very different between the two branches of the sector. Social Security is financed through three mechanisms: employee contributions (as a percentage of the total income), employer contributions (the same amount the employee has to pay) and government contributions. Mexico’s current health expenditure is 5.5% of GDP, compared to the Latin American mean of 8.01% (World Bank ND, a). The Popular Health Insurance scheme (PHI) is financed through individual contributions paid annually (estimated according to socioeconomic status), plus a base fee of one-quarter of Mexico’s City annual minimum wage paid by the individual, plus government contributions (Gomez et al. 2011). Both of these public systems entitle their users to a so-called basic health needs pack, which covers many diseases and procedures, but does not cover all expenses, so out-of-pocket payments for medications, curative materials and other procedures are common (World Bank ND, B).

Neoliberal policies that impacted the healthcare system

After understanding how the system works, it is necessary to analyze two of the major features of neoliberalism, which according to Fisk (2000) have impacted the Mexican healthcare system: privatization and labour flexibility. Mexico’s neo-liberal policies started in the 1980s, pushed by the World Bank’s debt reduction agenda (Laurell 2007). The idea, as Milton Fisk phrases it, “was that governments limit their involvement in healthcare and insurance and that they stimulate the growth of markets in both areas” (Fisk, 2000).

Privatization is one of the core values of neoliberalism (Navarro 2007). In Mexico, the privatization of the health sector started in 1995. A law was introduced stating that pensions (which were part of what was covered by the public sector’s health insurance) would be run by private corporations and that any individual or employer could request a cancelation of their public healthcare fees to pay for private insurance. In 1995 the public sector was already starved of funds and the law reform only meant fewer fees would be directed to the public sector. With higher paying jobs having a higher rate of reversion towards the private sector and only lower paying jobs contributing to the healthcare system, even less money was available to make the public system work, as the contributions are made as a percentage of one’s salary (Laurell 2007). To make things worse, the government did not make up for the losses by raising total healthcare expenditure, as the logic was that fewer people would use the system. These measures made health a commodity and not a public good, reducing the government’s accountability for health and causing the accessibility and quality of the public healthcare system to decline (Fisk 2000).

Another point of vulnerability of neoliberal policies applied to the Mexican healthcare system was labour flexibility. In an effort to align the Mexican economy to neoliberalism and in order for Mexico to be able to compete in the growing world economy, a variety of factors helped make labour cheaper and more flexible (Fisk 2000). Wages were not raised and the Mexican peso was devaluing rapidly, meaning the purchasing power of the average Mexican declined. The contributions of individuals to the public health system also declined in value, as wages were worth less, which is explained by three main factors: exports become cheaper to foreign customers so generating less revenue, imports become more expensive, and in the short-term, devaluation tends to cause inflation, making the price of products and services higher (Mankin, 2021). Furthermore, contracts were made more flexible and easily broken, as the government saw its job as protecting industry and not the employee. This made informal jobs a necessity for many Mexicans, leaving thousands without health coverage and the healthcare system without funds (Lopez-Arellano 2017).

To counteract these measures, the Mexican government created the Secretariat of Health PHI programmes in 2004 (Lopez-Arellano 2017). This was a set of programmes directed at people within the informal employment sector and previously unprotected groups like the unemployed, the elderly and people under the poverty line. In order to be enrolled, individuals had to pay an annual fee that was the same for everyone regardless of their income and was calculated using the minimum wage. This meant that the only option informal workers had in order to be protected by the health system was and, in some cases still is, to enroll themselves in one of the Secretariat of Health programmes. However, not everyone could afford to pay the fee, so thousands of people were left out of the health system, as paying the fee (even though it was supposed to be affordable) was out of reach to individuals living on less than the minimum wage.

In theory, broadening health coverage sounds appealing, but it made things worse for the people who were previously insured, as the government broadened coverage but didn’t do much to make the system grow. This lowered the quality of healthcare for everyone using the public health system, as hospitals that were previously only for formal workers were now used for everyone and the catalogue of interventions that are covered with no extra payment is less comprehensive each year (Laurell 2015). To exemplify this, one could look at the number of hospital beds available per 1000 users of the public health system: in 2005 there were 2.14 beds compared to 1.27 beds in 2016 (CONEVAL 2018 and INEGI 2018), making the system even slower and health access more complicated.

Counterarguments

Neoliberal policies can also have a positive side. The Mexican economy has grown steadily since the 1990s, with GDP per capita growing from 3,112 to 9,863 US dollars (World Bank ND, c), and people living on less than 1.90 US dollars a day going from 3.3% of the population to 0.5% in the last 30 years (World Bank ND, d). But with economic growth, inequalities grew as well, with the top 1% of Mexico’s earners enjoying 21% of the national income in 2012, and in 2014 the wealth of the top four billionaires equating to 8.5% of Mexico’s total GDP (LSE government blog 2020).

It can also be argued that the growth of the private sector created more jobs, however, the unemployment percentage of the total labour force in 1991 was 3.04% and 3.6% in 2020 (World Bank ND, e). A variety of variables could be responsible for unemployment not falling, the main one being that it could be considered a pretty low percentage of unemployment to begin with. However, informal employment numbers have risen since the 1990s (INEGI 2020), partly due to labour flexibility.

The modifications made to the public healthcare system did give more people access to it and gave the population the option to seek private insurance or visit a private practitioner. They also came with the cost of lowering the quality and efficiency of the public healthcare system, with over 20% of the population rating the public healthcare system as bad or very bad in the most recent Nacional Survey of Health and Nutrition, and waiting time being up to 120 minutes in public ambulatory healthcare facilities, compared with 20 minutes in the private sector (INSP 2020). It is also important to note that according to the same survey, health expenditure per month per capita didn’t vary too much between private and public healthcare users in urban settings, the former being 176.39 Mexican pesos and the latter 169.53 Mexican pesos, meaning in some cases public healthcare can be as expensive as private, but with longer waiting times and perception of lower quality.

It is also worth noting that neoliberal policies are not the only cause of the current under-funding and overcrowding of the Mexican public healthcare system. Last year, President Andres Manuel Lopez Obrador, a self-declared socialist (Beck, 2021), created the National Institute for Health and Wellbeing (INSABI). The Institute is supposed to provide free medical services to anyone and everyone (specifically workers of the informal sector and unemployed population) regardless of their social security status. This is a seemingly big step towards Universal Health Coverage, but this measure was made with no consideration as to how it was going to be funded, no government investment and no funding for additional medical staff or infrastructure. Furthermore, the programme is supposed to work with no user fees or voluntary insurance payments, meaning the INSABI programme further drains resources from existing public programmes. This suggests that the deterioration of the Mexican health system is due to more than neo-liberalism, but it can surely be stated that neoliberal policies initiated the change to an underfunded and overcrowded system.

Concluding remarks

 With this framework, it is possible to understand the decision of many to insure themselves and their employees with a private healthcare provider. Healthcare has been commodified and the public healthcare system has systematically been defunded by neoliberal policies that incentivize the use of private health providers, at the same time that the public system overextended itself. The Mexican government has slowly made itself less accountable for healthcare and health has become a commodity, not a public good.

Arguably, the group most affected by these policies is the low- and middle-income formal workers group, who contribute a percentage of their salary to pay for public health insurance and who can’t afford to make the change to private insurance. This group previously had a right to healthcare, in a less overcrowded and more efficient system. Providing every Mexican affordable access to healthcare should be a priority for the government, however, the overextension of a previously working system is prejudicial for individuals who formerly had access to it and does not offer the best service to new users.

The poorest sections of society, including informal workers and unemployed individuals, did not previously have access to healthcare and the countermeasures to the 1980s-1990s neoliberal policies allowed them a limited access, but access nonetheless. Furthermore, in the latest years the INSABI gave access to the most underprivileged groups, making UHC an attainable goal, however it caused a further overextension of the existing system. If this overextension is only temporary it could be argued the measures were justifiable and necessary. However, additional steps should be taken by the Mexican government to expand the system and increase its funding, to ensure everyone has access to healthcare, and individuals who were previously covered by the public health system still get timely and proper attention. Private health-insurance ought to be considered as an option, but it shouldn’t be the only option to quality care.

Bibliography

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Zhuo Li

Introduction

Childbirth is one of the critical factors to ensure human reproduction and sustainable development of the human species. There are four categories of human birth deliveries: natural birth, assisted delivery, caesarean section due to medical conditions, and caesarean section due to social factors (Chen & Tan, 2019). Caesarean section (C-section) is an important surgical procedure that could significantly reduce the maternal and perinatal mortality when medically justified, especially when complications arise during birth, such as abnormal position for labour and foetal distress. According to the World Health Organization (WHO), the ideal C-section rate should be between 10%-15% when either the mother or newborn’s health and life are not threatened (WHO, 2015). Beyond the threshold of 10-15%, C-section may be associated with an increased maternal and infant morbidity and perioperative mortality rate (POMR).

Although data on the benefits and risks of C-section is accumulating in the international healthcare community in the past decades, there is no evidence suggesting C-section delivery is beneficial for women or infants when there is no medical indication of necessity (National Research Council., 2013). Besides, like any other surgery, it comes with some short-term and long-term risks for the woman and infant, which may extend many years after the delivery. The major risks of morbidity and mortality to the mother would be haemorrhage, post-surgery infection at the operation site, the formation of scar tissue and difficulty with future deliveries (Mylonas & Friese, 2015). Furthermore, some evidence suggests that C-section delivered (CD) babies are more likely to develop autoimmune diseases (Neu & Rushing, 2011). This may be due to different methods of delivery that could influence the microbial exposure that happens at birth. C-section delivered babies are exposed less to the maternal bacteria than naturally delivered babies who pass through the birth canal, which can negatively impact the development of babies’ immune system (Björkstén, 2004). As a result, C-section delivered babies are more susceptible to health problems such as childhood asthma, obesity (Blustein & Liu, 2015) and type 1 diabetes (Boutsikou & Malamitsi-Puchner, 2011).

Global Rise of C-section

In recent decades, the overall rate of C-section at the population level has increased steadily in most developed and developing countries (Betrán et al., 2016). Recently, the Lancet group designed a study to assess C-section use within 169 countries and found that worldwide C-section rate almost doubled from 2010 (12.1%) to 2015 (21.1%) (Ties et al., 2018a), of which, the difference in frequency of C-section usage between regions and individuals countries is noticeable (see figure 1) (Sinnott et al., 2016).

It is important to note that among 169 countries in the research, over half of the countries have >95% of health facility births. The doubling of worldwide C-sections was partly driven by an increase in the proportion of labour occurring in health facilities, especially in South Asian countries (Ties et al., 2018a). This is largely because most women believe that it is safer to give birth in a hospital than anywhere else, and better for both maternal and foetal health (Maru et al., 2016). In China, under the influence of ‘one-child policy’, a typical Chinese family with four grandparents and two parents have been more likely to choose a safer method of childbirth for the family’s only child over recent decades (Merli & Smith, 2002).

In addition, hospital births in China have increased from 44.3% in 1988 to 94.7% in 2008 (Feng et al., 2011) and reaching over 99% in 2018 (McNeil, 2017). From 1993 to 2017, the Chinese overall C-section rate increased from 5% to 46% and reached up to 60% in some urban areas (Wang & Hesketh, 2017). The rate is much beyond the WHO suggested 10-15% threshold, and large proportion of these are C-sections due to social factors. which may put both mother and infant at risk (Chen & Tan, 2019). These trends suggest that the Chinese health facilities may not able to cope with the increased attendance and need for emergency life-saving C-sections due to limited public health care resources such as doctors, nurses and beds that are required for emergency C-sections (Ties et al., 2018a). Besides, it is worth noticing that C-section is more costly than vaginal delivery due to the use of anaesthetics and prolonged average length of stay in hospital (Cegolon et al., 2019). In large Chinese cities such as Beijing, the price of vaginal birth is about 6000 RMB (US$1000), whereas C-section costs at least 12000 RMB ($2000) in some top-level hospitals (Mi & Liu, 2014). This overall suggests the overuse of C-sections in China will contribute to economic and public healthcare resource burden.

Therefore, analysing factors that contribute to the overuse of C-section should be a global concern and reducing unnecessary C-section and improving access to C-section when medically justified should become a national priority in China. In this blog, the contributing factors to this increased percentage in C-section in China will be discussed, alongside possible interventions.

The Robson Classification and Betrán et al.’s Framework

In order to identify factors that contribute to C-section use, a universal classification system is required to meet current international and local needs. Decades ago, there was no globally accepted classification system for C-section that allows the researcher to make relevant comparisons of C-sections across different facilities, cities and countries. In 2014, WHO suggested the use of the Robson classification system as a global standard C-section classification for accessing, monitoring and comparing C-section use within or across different level healthcare facilities (WHO, 2015). As shown in figure 2, the Robson classification system classifies all women into ten categories based on the following five essential obstetric characteristics:

• number of fetuses (single or multiple)
• fetal presentation (cephalic, breech or transverse)
• previous obstetric record (nulliparous or multiparous, with or without uterine scar)
• the onset of labour and delivery (spontaneous, induced or pre-labour C-section)
• gestational age at the time of delivery (WHO, 2015)^.

The key benefits of this classification system are that it is simple to use, reproducible, prospective and clinically relevant. The ten Robson categories allow healthcare professionals to classify every woman that is admitted for delivery based on their essential obstetric characteristics. This system helps institution-specific monitoring and auditing, and provides standardised comparison of data across institutions, countries and timepoints within the population, allowing researchers to identify the subpopulations driving changes in C-section rates. Meanwhile, it gives researchers the opportunity to make further subdivisions within each group to identify the associated factors that contribute to the use of C-section, such as socioeconomic and cultural factors (WHO, 2015), to assist them to develop evidence-based interventions and programmes to address the contribution of specific obstetric populations to changes in C-section rate (Nakamura-Pereira et al., 2016).

There are global concerns about the rising trend of C-section use with wide variation in rates across countries (Panda et al., 2018). Underuse of C-section could contribute to maternal and perinatal mortality and morbidity. By contrast, evidence suggests that overuse of C-section has not shown benefits but harm for maternal and perinatal health (WHO, 2015). The interventions to reduce unnecessary C-section use have shown very limited success. Exploring the subpopulations driving changes in C-section rate and identifying factors influencing the use of C-section has become critically important, as it would be a prerequisite for the development of evidence-based interventions (Kingdon, Downe & Betran, 2018).

Recently, Betrán et al. have developed a framework which represents both clinical and non-clinical factors related to women, society and healthcare organisations that influence C-section use (Betrán et al., 2016). As figure 3 represents, the innermost ring represents the Robson classification, which are clinical factors associated with C-section use. The outer three circles represent non-clinical factors associated with C-section use, which could be classified into three different perspectives that are related to women: communities, health providers and health care organizations. The diagram is intended to show that many levels of non-clinical factors are involved in C-section decision making and that reducing unnecessary C-sections is a complex process (Betrán et al., 2016). Meanwhile, research suggests that Robson classification systems could be used as a non-clinical intervention to reduce unnecessary C-section, as it will increase obstetricians’ awareness in patient classification, and improve the appropriate use of C-section (Senanayake et al., 2019). The Robson classifications have shown a significant impact in Brazil, to encourage natural birth after C-section to reduce repeat C-section procedures (Nakamura-Pereira et al., 2016).

Factors Influencing Rising Caesarean Section Rate in China

Women and community factors

The main reason many women prefer C-section delivery is that they perceive it to be safer than vaginal delivery for both maternal and foetal health (Diema Konlan et al., 2019). Fear of childbirth is another key factor driving C-section use (Betrán et al., 2018). As a surgical intervention, C-sections are performed with anaesthetics, which is expected to be less painful than natural birth. Hildingsson et al. suggest that women are more likely to change their delivery method to C-section due to the fear of labour pain and other labour effects, such as pelvic floor damage, urinary incontinence, urinary retention and sexual dysfunction (Hildingsson et al., 2002). The fear of pain and labour could also be a source of anxiety for many pregnant women (Quoc Huy et al., 2019).

Since pain and anxiety are correlated with each other, it could significantly influence experience of labour (Tzeng et al., 2017). A national survey of Canadian women suggested that 9.3% of women have experienced a negative birth experience (Smarandache et al., 2016). Such negative experiences could cause more stress in the following pregnancy, which can lead to the woman’s fear of childbirth and influence their choice of labour pathway (Guittier et al., 2014). Besides, social media has a growing influence on women’s preference for elective C-section (Mazzoni et al., 2011). Some women prefer to deliver by elective C-section because it is more convenient, fashionable, and it gives them more control in deciding when their baby is born, which can also reduce some anxiety of waiting for labour to start (Amyx et al., 2018). Research shows that women who had given birth through C-section previously were more likely to choose C-section again (Smarandache et al., 2016).

Furthermore, cultural perceptions and myths also play a critical role in the choice of delivery model in many countries (Betrán et al., 2018). For instance, research suggests that traditional Chinese culture had the most substantial influence on the decision of the model of birth delivery in China (Shen & Li, 2019). It is a common superstition in China for people to pick auspicious dates with specific time from the Lunar calendar for important events. In order to keep this tradition, some women choose to select a specific date with a specific time for C-section (Raven et al., 2015).

Health professional factors

Although pregnant women are often considered the most critical factor in determining the method of labour (Ghotbi et al., 2014), the physician or obstetrician is often the one to make clinical decisions and choices of delivery mode in many countries (Betrán et al., 2018). A study that surveyed 1,530 obstetricians within eight European countries showed that fears about litigation and working in university-affiliated hospitals are the key factors influencing obstetricians’ decision-making and agreeing to women applying for elective C-section (Habiba et al., 2006).

In many countries, the relationship between doctors and patients is tense (Jing et al., 2013). Doctors have to bear strict legal liability and are ethically obligated to protect the patient’s rights, benefits and cause no harm to the patient (Edwin, 2008). Some legal misconduct lawsuits put healthcare providers in a vulnerable situation, even if they provide the best evidence-based care to the patients. As a result, even if there is no evidence of medical malpractice or error, healthcare providers are more likely to be sued for complications during vaginal delivery rather than unnecessary use of C-section (Studdert et al., 2006). Besides, there is a lack of training, clinical experiences and proper skills in vaginal delivery among some junior obstetricians (Betrán et al., 2018). Lack of confidence in assisted vaginal birth when complications arise have been associated with the increased use of C-section, especially in environments where there is little communication between senior and junior obstetricians (Litorp et al., 2015).

In addition, a recent qualitative study among Indian gynaecologists found that besides above-mentioned maternal demand, low procedure risks factor and fear of litigation factors; obstetrician time and convenience also play an essential role in the decision-making process (Peel et al., 2018). This is because most C-section delivery is performed during weekdays and working hours, in order to combine work and private life, performing elective C-section with scheduled time would be more convenient for obstetricians (Habiba et al., 2006). Furthermore, in some but not all cases, the rate of C-section use is much higher in the private sector than in the public sector. For example, the C-section rate in some Chinese private hospitals has reached 90%. A large financial incentive has been provided to the obstetricians on C-section in the private sector, as private maternity care usually accounts for a majority part of hospital incomes (Zhang et al., 2019).

Organizational and system factors:

As mentioned above, under the influence of previous Chinese one-child policy, most Chinese families have chosen a safer birthing method for the pregnant woman and the family’s only child, which has contributed an increased rate of C-section use (Liang et al., 2018). In 2015, a new two-child policy was announced to replace the one-child policy. A study found that the C-section rate declined slightly after the release of the two-child policy (Yan et al., 2020), and women who intended to have a second child have reduced their preference for C-section delivery (Zhang et al., 2019). This is because there is a potential risk of uterine rupture at the site of previous C-section scar in the subsequent pregnancy (Abdelazim et al., 2018). However, interestingly, an increasing trend of C-section was observed 2-3 years after the two child policy (Yan et al., 2020). This demonstrates the complexity of the factors that influence the frequency of C-section and the reason for this phenomenon needs further investigation. Under the influence of the two-child policy, it is important to promote childbirth education to the public; to ensure pregnant women and health care professionals are both aware of the benefits of natural birth and potential risks of C-section in related to the subsequent pregnancy.

In addition, national socioeconomic status is one of the key factors influencing the C-section use. Recent Lancet research suggests the use of C-section is significantly higher in countries with a higher level of socioeconomic development, a higher level of urbanization, and higher density of physicians. However, when the analysis was limited to countries that overuse C-section (i.e. >15%) such as Brazil and China, none of the determinants had a significant correlation with the frequency of C-section use (Ties et al., 2018a). Chinese healthcare services are mainly dependent on the private ‘out of pocket’ payment (Liu et al., 2006). C-section is more profitable than vaginal delivery due to the use of anaesthetics and prolonged hospitalisation time (Cegolon et al., 2019). Hence, it is argued that more C-sections were performed for the financial incentive (Wang & Hesketh, 2017).

As public healthcare providers are government-controlled, public healthcare providers in China have to reduce their average hospitalization cost according to the “price transparency policy” issued by the Chinese government. This has helped to protect the rights of women of lower socioeconomic status and ensure their right to access C-section services based on medical indications. As a result, economic concern associated with C-section has become less of a concern for patients from the middle and higher socioeconomic groups (Li et al., 2017). However, prolonged hospitalisation time of C-section can overload public healthcare resources. The large volume of care with limited resources has contributed to long waiting lists and the overcrowded environment in public hospitals – putting patients with low socioeconomic status into a vulnerable state (Sufang et al., 2007). In order to further control the unnecessary C-section rate, more intervention needs to be considered (Liu et al., 2018), such as development of a multidisciplinary team culture.

Midwives are healthcare professionals who can provide primary prenatal and postnatal care and support for women in non-complicated pregnancies and deliveries (Sehhatie et al., 2014). Midwifery practice and maternity services are quite common in many western countries, such as the United Kingdom, Switzerland and Australia (Brodsky, 2008). In China, midwifery practice is closely associated with government policy and social factors. The role of midwife was abolished in 1993, as their role was considered unnecessary when all maternity care became hospital-based and obstetrician-led (Cheung, 2009). Midwifery training was only reintroduced in recent years (Cheung, 2009). Midwifery practice is preferred by Chinese obstetric nurses or obstetricians nowadays to reduce their excessive workloads; and the Chinese government has emphasised the need to increase the number of midwives in order to reduce the pressure and workload on obstetric nurses and obstetricians (Likis, 2014) and to meet additional demands especially after the release of two child policy (Cheng & Duan, 2016). Nowadays, midwives are usually supervised by the senior obstetricians and collaborate closely with other maternity care professionals to provide prenatal and postnatal care in hospitals as nurse-midwives. However, since most of the current serving midwives received a relatively low-level education, this has contributed to the fact that they are usually under the supervision of senior obstetricians (Li, Lu & Hou, 2018).

Possible interventions

Family/Champion group workshop

Increasing public awareness is vital in avoiding unnecessary C-section delivery. There is a statistically significant relationship between C-section rate, risk awareness and maternal education level globally (Redha & Khairi, 2017). As mentioned above, the feeling of fear, anxiety and worry and misinformation about safety are two key factors that influence the women and their families’ choice of delivery (Betrán et al., 2018). Evidence suggests that specific birth education programmes could help women and their families cope with fear and anxiety (Chen et al., 2018). Moreover, studies from the United States (Feinberg et al., 2015) and Iran (Valiani, Haghighatdana & Ehsanpour, 2014) have shown that nurse-led birth education and relaxation training programmes correlate with a significant increase in the overall frequency of spontaneous vaginal births. Therefore, Chinese hospitals could try to provide childbirth education leaflets to women who go for antenatal tests and conduct champion group workshops for women and their families. Such interventions may help women and their families cope with fear and anxiety, and understand the benefits of natural delivery, risks of C-section, as well as tips for managing labour stress, thereby increasing their confidence in having a natural birth.

Pairing of midwives, junior and senior obstetricians

As mentioned above,lack of training, clinical experiences and adequate skills on assisted vaginal delivery could be one of the major factors that influence some junior obstetricians’ preferences for C-section (Betrán et al., 2018). Therefore, creating a multidisciplinary team culture could allow obstetricians and midwives to make communication effective and share clinical opinions based on their experiences. For example, junior obstetricians could pair up with a senior obstetrician or a midwife and use mobile chat applications such as WeChat to seek timely advice about the necessity of the procedure. With assistance from midwives and experience from senior obstetricians, junior obstetricians are expected to gain confidence in assisted vaginal delivery from clinical practice over time. However, midwives and senior obstetricians’ enthusiasm are the key influences on this intervention.

Conclusion

C-section is a lifesaving procedure when medically justified. In the past decade, there has been a steady increase in the use of C-section globally. The population C-section rate in China is far beyond the WHO recommended threshold (10-15%). Such overuse of C-section will not only put both maternal and infants’ health at risk but also contribute an economic and public health resource burden. Thus, emphasising the use of C-section when medically justified should become a national priority in China.  Still, there are many challenges associated with it across different individual, societal and cultural levels.  Possible interventions designed according to the countries’ need and this need should be defined through investigating the factors for the overuse of C-section at a local level.

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Raquel Thalheimer

In 2016, Ruth Beni’s film, Needlecraft, won the gold medal at the New York Film festival. Beni, a British activist and filmmaker, created the film on the subject of Female Genital Mutilation (FGM) for the Guardian as part of their campaign to end the practice of FGM (Carson, 2016). Although only three minutes long, the film is highly effective at evoking emotion. Needlecraft opens with playful music and vibrant colours as the viewer is introduced to the film’s protagonist, a bubbly baby girl named Maria (see Figure 1) .

Suddenly, the music takes an ominous turn and Maria is plucked from the screen, changing from a 2D needlepoint character to a 3D clay figure. First, her ear is cut off with scissors and the remaining hole is sewn shut. Next, her nose is sliced off with a scalpel. Finally, her mouth is sewn shut. Maria is left sitting on the ground, alone and disoriented. As the screen fades to black, the narrator rhetorically asks, “a girl is perfect, why cut her?”

The act of cutting, slicing, and sewing are vivid representations of female genital augmentation, often referred to as Female Genital Mutilation (FGM), Female Genital Cutting (FGC), or both (FGM/C). The final act of sewing Maria’s mouth shut, signifies a loss of power and autonomy within the situation. The perspective captured in this film reflects Western-held notions of FGM/C and human rights. While this viewpoint constructs a large part of the global narrative, it is just one side of the story.

In this blog, I use Beni’s film as a thought piece for examining two dominant narratives surrounding FGM/C. I explore both the Western-framed perspective adopted among international health and development organisations, as well as the social, cultural, and religious perspectives found among pro-FGM/C communities and scholars. I conclude with a discussion of the opposing Rights perspectives at play. For enhanced clarity, I have divided the discussion into the following segments: background, prevalence, procedure, narrative, Rights and FGM/C, the costs of FGM/C, and Discussion.

Background

Although FGM/C has existed for centuries, the focus on FGM/C prevention programming has increased over the past 50 years due to a growing interest in gender within the development field (Harcourt, 2016). In 2015 advocacy surrounding the abolition of FGM/C experienced another resurgence following its inclusion in the United Nations Sustainable Development Goals. Specifically, goal five identified the elimination of “all harmful practices, such as child, early and forced marriage and female genital mutilation” as an international priority (United-Nations, 2015).

Prevalence

While FGM/C has declined in the past decade (United Nations, 2015), it is estimated that between 100 million (World-Health-Organization, 2008) and 200 million girls and women have undergone FGM/C globally (UNICEF, 2019). Although FGM/C is most commonly associated with parts of Africa, some countries in the Middle East and parts of Asia participate in the ritual (Evans, 2019). Among practicing countries, prevalence rates vary drastically, ranging from under 1% to over 90% (UNICEF, 2019).

Procedure

In a 2008 statement, FGM/C was clinically defined as “procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons” (World-Health-Organization, 2008). The procedure ranges from Type I, removing part of the clitoris, to Type III, infibulation, “whereby most of the clitoris, labia minora, and part of the labia majora are excised, and the remaining vaginal tissue is stitched to leave a small orifice for urination and menstruation”. Type IV is reserved for other “nonmedical” genital modification, such as genital piercing (World-Health-Organization, 2018). In addition to varying prevalence, the type of FGM/C commonly practiced varies greatly by country and community (Morison et al., 2001). Most girls undergo FGM/C around the age of puberty,but the practice can be performed as young as age five (Small et al., 2019;NHS, 2019).

Typically, FGM/C practitioners are older women or “midwives” who hold a prominent status within their community (Evans, 2019; Kalev, 2004). In some communities, the profession is passed down from one generation to the next, further cementing the ritual and cultural significance of the event (Small et al., 2019).

Narrative

The language used by the organisations providing these definitions frames FGM/C using a Western biomedical lens. Terms such as “injury”, “non-medical”, and “harmful” leave little ambiguity regarding the stance held by organisations such as the WHO, UN, UNICEF, UNHR, and others, on the act of FGM/C. The choice of the word “mutilation”, a term commonly found in health and development discourse, is value-ridden and pejorative (Evans, 2019).

While global health and development organisations focus on the physical procedure of FGM/C, proponents of the practice emphasize its social, cultural, and religious importance. Some pro-FGM/C scholars stress that although the procedure can be painful, the experience prepares women for childbirth pain and that many girls endure the procedure “without flinching to demonstrate maturity and a readiness to face the hardships they often encounter” (Small et al., 2019). Among communities where FGM/C is common, un-cut girls are often the subject of social exclusion and humiliation (Small et al., 2019). FGM/C is seen as a necessity to ensure societal inclusion and elevate one’s social status, thereby increasing marriage prospects. It is believed that the modification of female genitalia will decrease a woman’s sexual desires and stave off extramarital sexual relations, while also enhancing sexual pleasure for their husbands (World-Health-Organization, 2018). While many communities cite a religious component of the practice, FGM/C is not expressly mentioned in religious texts such as the Quran or the Bible (World-Health-Organization, 2016;Andarge, 2014). The above beliefs reflect the high priority cultures practicing FGM/C place on domestic life and marital success.

Notably, international organisations are far less likely to apply a moral critique or lens to elective cosmetic genital surgeries common amongst women in the West, despite their similarity to some types of FGM/C. Female Genital Cosmetic Surgery (FGCS) is defined as “non-medically indicated cosmetic surgical procedures that change the structure and appearance of the healthy external genitalia of women, or internally in the case of vaginal tightening” (RACGP, 2015). These surgeries can include a variety of procedures ranging from labiaplasty, clitoral hood reduction, hymenoplasty, labia majora augmentation, vaginoplasty, and G-spot amplification. (Committee-on-Gynecologic-Practice, 2020). Patient interest in, and performance of, cosmetic genital surgery have increased dramatically over the past several decades. For example, labiaplasty rates in the United States increased by over 50% between 2014 and 2018 (Committee-on-Gynecologic-Practice, 2020). Although medical professionals recognize that these procedures are not deemed “medically necessary”, they are often framed as symptoms of Western culture’s emphasis on a particular aesthetic, without the same judgemental language used to describe FGM/C.

Rights and FGM/C:

Several prominent organisations including UNICEF and the WHO have strongly condemned FGM/C (Small et al., 2019). Citing the 1948 UN Universal Declaration of Human Rights statement that “everyone has the right to a standard of living adequate for health and well-being”, UNICEF asserts that FGM/C is an infringement on girls’ and women’s human rights (2019). Contrarily, pro-FGM scholars argue that negative views of FGM/C are “a neocolonial stunt of Western ideology” meant to embarrass those who practice the ritual (Small et al., 2019).

            Ultimately, the topic is best explored through an examination of the concepts of Rights within global health and development. The two dominant perspectives are that of a cosmopolitanism versus communitarianism view of human rights.

            By asserting that FGM/C is a violation of human rights, UNICEF and analogous international aid organizations embody a cosmopolitan perspective of Rights grounded in a universal moral claim to individual human rights. They argue that reason is a shared capacity among all humankind and should be used to construct moral principles to “deliver humankind from the mire of ignorance and superstition” (Prokhovnik, 2016). Proponents of this viewpoint emphasize the long-term negative impact of FGM/C on girls’ mental and physical well-being as an intrusion of their right to living a high quality of life (Evans, 2019).

            Conversely, those who practice FGM/C and scholars who support the practice represent a communitarian approach, taking into consideration the culturally specific nature of rights (Prokhovnik, 2016). A communitarian perspective would argue that every component of this debate is inappropriately framed using a conception of human rights built upon Western ideologies. Communitarians assert that while all cultures have a moral system and notion of rights, the content of these systems vary greatly (Kalev, 2004). For example, since most individuals undergo FGM/C during puberty, a Western perspective would claim that these individuals are minors, thereby further compounding the unjust infringement on their rights. On the other hand, some scholars, such Henriette Dahan Kalev, argue that while some recipients of FGM/C may be considered “minors” by Western standards, they could already be regarded as adults within their culture (2004). Therefore, even the concept of being a “minor” is culturally construed and to apply a Western definition to other parts of the world is to superimpose Western ideals and philosophies on other cultures. Within cultures that practice FGM/C, being a child or “minor” may hold a different meaning. Some individuals who undergo FGM/C may already be considered adults within their culture (Kalev, 2004). Accordingly, pro FGM/C scholars argue that those who oppose the practice are applying their Western, liberal, often feminist, ideology to local cultures in a way that is antithetical to those cultures’ values and way of life (Small et al., 2019).

            While the above discussion illustrates the challenges in framing and understanding rights and FGM/C, it also helps to illustrate the difficulty in comparing the rights narrative between FGM/C and FCGS. The agency of children and women to make choices for themselves and their bodies cannot be compared, whether that choice is to undergo FGM/C or FGCS. Therefore, if the two practices are to be compared, they must be done using parallel parameters. Interestingly, the Western health community does not tend to distinguish between age when advocating for the abolition of FGM/C. For example, in the United States, many States have passed legislation to abolish FGM/C for all girls and women, including those over 18, the age of consent in the United States (Aha-foundation, n.d.). This indicates a Western opposition towards FGM/C that is based on values other than age or consent.

Costs of FGM/C:

            While both perspectives offer compelling points for consideration, the long-term morbidity, and in some cases mortality, resulting from FGM/C are impossible to refute. Women who undergo FGM/C are reported to experience a host of short- and long-term consequences, including urinary incontinence, difficulty voiding urine, painful sex, infertility, prolonged labour, increased risk of stillbirth, vaginal cysts, bacterial infections, irregular menses and higher prevalence of herpes (World-Health-Organization, 2016;Morison et al., 2001;Matanda et al., 2019). Additionally, some studies suggest there is an increased risk of HIV infection and fistulas within this population (Matanda et al., 2019;Morison et al., 2001). Although pro-FGM/C scholars argue that girls and women do not experience psychological trauma when seeking out FGM/C for cultural reasons, many researchers assert that the procedure is associated with serious, long-term, psychological damage (Matanda et al., 2019;Small et al., 2019;Abdalla and Galea, 2019). While cultural sensitivity and framing are essential to understanding and explaining health-related practices, the negative impacts of FGM/C on women’s mental and physical health cannot be denied.

            Similarly, Female Genital Cosmetic Surgery is not without potential consequences. Women who undergo FGCS can face ramifications including “pain, bleeding, infection, scarring, adhesions, altered sensation”, difficult or painful sexual intercourse, pyschological distress, tearing of scar tissue during childbirth following FGCS, wound dehiscence and the need for reoperation (Committee-on-Gynecologic-Practice, 2020;RACGP, 2015). Furthermore, since FGCS is an elective procedure, it is assumed that women have consented to undergo FGCS. However, while these women may have consented to the procedure, they may also be subject to coercion, either implicitly or explicity, due to society’s expectations and representations of female bodies. In this manner, the ability of some women seeking FGCS to consent to the procedure could be debated. Regardless, even if women who pursue FGCS are adult, consenting women, the physical toll of genital surgery is incontestable, regardless of who performs or receives the procedure.

Discussion

When exploring the subject of FCM/C, there are convincing arguments presented on both sides of the debate. However, I support efforts to abolish the practice, due to the strongly established relationship between FGM/C and resulting negative physical and mental health.

However, while global health communities are steadfast in their opposition to FGM/C, they are less firm in their opinion of Female Genital Cosmetic Surgery; despite the similarity between FGM/C and certain FGCS procedures. As previously mentioned, anti-FGM/C organisations run the risk of promoting cultural imperialism. This risk is particularly evident when considering the different perspectives surrounding FGM/C and FGCS.

The primary arguments against FGM/C is that it is a procedure forced upon young women and girls which intentionally mutilates the female anatomy with the end goal of diminishing sexual pleasure. In turn, this procedure, and the associated sexual demureness it supposedly provides, are associated with enhanced marriage desirability in the eyes of potential suitors and the community at large. Although there are secondary gender equity and physical harm considerations among those who oppose FGM/C, the pinnacle of the argument largely stems around the lack of autonomy among the women and girls who undergo FGM/C. As previously discussed, the concept of consent applied is one based in Western philosophy.

By contrast, women who engage in FGCS are willing, consenting, participants in a medical (although not medically necessary) procedure. Although deemed equivalently nonessential by the American College of Obstetricians and Gynaecologists, and potentially as dangerous, FGCS is not regarded with the same moral distain as is FGM/C (Committee-on-Gynecologic-Practice, 2020).

This distinction raises a few points for consideration, chiefly at what point does societal pressure constitute coercion, and to what degree do individuals and the global health community regard female genital modification differently based on the population undergoing these procedures. Beginning with the latter, there is ample criticism that the legal and moral objection to FGM/C compared to FGCS is highly inconsistent given the similarities between the procedures and the reasoning behind them, and is influenced by the communities who undergo each practice (Dustin, 2010). Those in favour of this perspective argue that the unequal treatment of these topics reflects an inability of Westerners to accept the perspective of those who practice FGM/C for cultural, social, and religious reasons (Ahmadu et al., 2001;Kirby, 1987).  Some scholars have taken the argument a step further, positing that the difference in treatment is rooted in racism and neo-colonial ideology (Earp, 2016). To ignore the disparity between the global health community’s view of FGM/C versus FGCS would be a significant oversight. While many scholars have recognised the similarities between the two practices, both in their physical manifestation and in their cultural basis, both scholars and lay persons tend to hold the two practices to different moral standards.

Furthermore, those who oppose the practice of FGM/C argue that participants are coerced due to familial, societal, religious and cultural pressure. However, the primary reason women cite for their desire to undergo cosmetic genital surgery is to achieve the idea of  “normal” genitalia directly propagated by Western society and the pornography industry, and implicitly encouraged by prominent fashion trends ranging from genital grooming to undergarments (RACGP, 2015). Moreover, the desire to change the appearance of one’s genitalia may be influenced by romantic partners, family or friends. In this manner, women who seek FGCS face identical societal and cultural pressure to undergo genital augmentation as women living within communities where FGM/C is prominent. At what point does societal pressure, and a desire to meet mainstream beauty standards, converge on coercion? Having established the similarities in the physical procedure, possibility of adverse events, and socio/cultural influence, the remaining difference in treatment between the two procedures can largely be attributed to differing treatment among the populations who pursue these types of genital augmentation, and a bias towards elective biomedical procedures over elective religious procedures.

While there are serious adverse effects associated with FGM/C, global health campaigns aimed at abolishing the practice on the basis of a universal infringement of bodily rights, without applying the same analysis to FGCS, fail to fully appreciate the complexity of female genital augmentation.

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Daryl Blades

Introduction

Typically, development of a country is thought of in terms of basic health care, education, industrialisation and economic growth (United Nations Development Programme, nd). The UN classifies a country’s level of development by measuring its gross national income per capita (UN, nd). However, an article authored by Peter Uvin conveyed a change in international development discourse when he outlined the manner in which development has evolved to incorporate human rights and the concept of development as a human right (Uvin, 2007). In the book “Development as Freedom”, written by economist and philosopher Amartya Sen, a holistic approach was adopted to define development “as a process of expanding the real freedoms that people enjoy” (Sen, 1999: 3). Sen theorised that political, social and economic freedoms underpin development by being both the means and the ends to its achievement. Based on Senian theory, the argument that no country is developed until all freedoms can be exercised, allowing individuals to “lead the kind of lives they have reason to value” (Sen, 1999: 10) resonates, especially in a developed country.

Ireland

Recent societal developments in the Republic of Ireland/Éire (hereafter “Ireland”) were heralded by the Irish musician Hozier in his single “Nina Cried Power”, released on 7^th September 2018 (Hozier, 2018). The song is performed by Hozier alongside Mavis Staples, an American gospel singer and civil rights activist. The anthem celebrates famous musicians who were also political and civil rights activists, such as Nina Simone, James Brown, John Lennon and Bob Dylan, to name but a few. A music video accompanied the launch of this single, featuring prominent Irish activists listening to the powerful lyrics celebrating change. The activists included in Hozier’s video come from varying ethnicities, social backgrounds and whose work span across different decades and themes. Undoubtedly, all 21 featured activists have shaped the development of Irish society by advocating for freedoms to better the lives of Irish citizens. This blog aims to provide a brief overview of three topical areas of development within Irish society which emerge from Hozier’s video: LGBTQ+ rights, women’s reproductive rights and asylum seeker rights. The activists commemorated for their work in securing these rights in the development of an already ‘developed’ Ireland, are featured below.

LGBTQ+ rights

Until 1992, homosexuality was officially considered a mental illness by the World Health Organization, which removed it from its International Classification of Diseases (ICD) with the publication of ICD-10 in that year. Homosexuality was subsequently decriminalised in Ireland in 1993 after Senator David Norris successfully argued the criminalisation of male homosexuality in Ireland violated Article 8 of the European Convention on Human Rights; violating his right to privacy (Norris -v- Ireland, Case No. 6/1987/129/180) (ECHR, 1988). Up until that time, homosexuality was taboo in a very conservative Catholic Irish society.

A period of acceptance and silence by the Irish LGBTQ+ community followed the decriminalisation of homosexuality. This was arguably due to the achievement of basic equality, however, within the last decade and a half, Irish LGBTQ+ campaigners have found their voice, culminating in Ireland becoming the first country in the world to legalise same-sex marriage by popular vote in May 2015 (Irish Times, 2015). Following this, Ireland’s first openly gay Taoiseach (leader of the Irish government) was appointed in June 2017.

Two activists referenced by Hozier on the contribution of human rights to the LGBTQ+ community in Ireland are Sam Blanckensee and the ‘Queen of Ireland’, Panti Bliss. Sam Blanckensee is a transgender rights activist who, as a National Development Officer in Transgender Equality Network Ireland (TENI), helped to promote and obtain gender recognition legislation in Ireland in 2015 (Irish Statute Book, 2015). The Gender Recognition Act, 2015 enables Irish citizens to obtain a new birth certificate with a self-declared gender. Blanckensee’s achievements reached global recognition when they/he was included in Forbes’ Europe list of 30 under 30 in 2017 (Forbes, nd).

Irish Drag Queen Panti Bliss began a global discussion on LGBTQ+ rights when her influential ‘Noble Call’ speech at the Abbey Theatre in Dublin went viral in 2014 (O’Neill, 2014). In her impassioned call to activism, Panti Bliss illuminated the daily inequality experienced by LGBTQ+ people living in Ireland. Since then, she has worked for the Irish Department of Foreign Affairs advocating for LGBTQ+ rights around the world, giving a voice to this minority community (Hozier, nd.a).

Women’s reproductive rights

Another recent development in Irish society was the expansion of women’s reproductive rights and bodily autonomy in 2018. It is thought that in total over 170,000 Irish women have travelled abroad to seek legal termination of their pregnancies (Fischer, 2019). The magnitude of this exodus was captured when a floating clinic set up by the Dutch NGO “Women on Waves” docked in Dublin and Cork in 2001. Originally, the clinic intended to provide abortion services to Irish women, however, they were unable to obtain a licence to carry out their services. Nonetheless, within a few days of their arrival in Ireland, hundreds of women reached out to the ship for counselling services (Women on Waves, nd).

The death of Savita Halappanavar from a septic miscarriage in 2012 brought Ireland under global scrutiny with its restrictive abortion laws (HSE, 2013). Since 1992, multiple legal challenges have been brought before the Irish courts by women who were denied legal abortions and in which Ireland was found to be in violation of the European Convention on Human Rights (Irish Family Planning Association, nd).

The ‘Repeal the Eighth’ project launched by Anna Cosgrave sparked a wave of unity within the pro-choice movement leading up to the 2018 referendum on the repeal of the Eighth Amendment to the Irish Constitution. The Eighth Amendment gave the equal right to life of the unborn and to the child’s mother (Irish Statute Book, 1983), making abortion effectively illegal. Cosgrave designed a simple black crewneck sweater with the word ‘REPEAL’ emblazoned across the chest. The black sweater signified solidarity with Irish women who had no choice but to travel abroad to seek basic abortion services. The REPEAL campaign sought to remove stigma surrounding this sensitive issue and opened a forum for discussion, especially for women living with the shame of obtaining abortion outside the State (Hozier, nd.b).

Saoirse Long bravely shared her personal story of abortion (Long, 2018) which challenged anti-abortion discourse present within Irish society since the 1960’s (Delay, 2019). Both these feminist activists helped to bring about the availability of safe and legal abortions in Ireland. An overwhelming vote in May 2018 saw the revocation of the Eighth Amendment to the Irish Constitution by popular referendum with a result of 66.4% in favour (RTÉ, 2018). Ireland’s societal development finally mirrored the 1960’s second-wave feminist movement “The Personal is Political”, whereby inequality within the private sphere was opened up to political scrutiny (Nicholson, 1981).

Asylum seeker rights

In 2018, the Office of the Refugee Applications Commissioner in Ireland received 3,673 applications from asylum seekers seeking refugee status (UNHCR, 2018). According to the UN Refugee Agency, “an asylum-seeker is someone whose request for sanctuary has yet to be processed” (UNHCR, nd). Asylum seekers are legally entitled to stay in the State until their application for protection is decided. Whilst awaiting the result of their application for refugee status in Ireland, asylum seekers are housed in communal temporary state-provided accommodation called “Direct Provision Centres” (Irish Refugee Council, nd). The majority of Direct Provision Centres are run by private contractors on a for-profit basis on behalf of the State (Irish Refugee Council, nd). These centres were initially designed as a short-term measure in 2000, however, at the end of 2018 over 6,000 asylum seekers were living in 39 Direct Provision Centres, with the average length of stay being 23 months (Reception and Integration Agency, 2018). Concerns have been raised regarding Direct Provision Centres since their introduction twenty years ago. They have been described as a human-rights abuse, institutionalising already marginalised groups which can be detrimental to personal development (Irish Times, 2019).

Activists Lucky Khambule, Ellie Kisyombe, Blessings Moyo and Victoria Chihumura all came to Ireland as asylum seekers and lived as refugees in the direct provision system. Ellie Kisyombe (originally from Malawi) was the first person living in the direct provision system to run for local election in Ireland (The Times, 2018). Victoria Chihumura (from Zimbabwe) successfully completed tertiary education despite living in the tough conditions of direct provision. All featured activists have become advocates for immigrants living in Ireland within the direct provision system, rallying for equal rights to education, combating racism, promoting integration into society and campaigning to abolish direct provision.

Significant developments for Irish refugees have come into operation over the last two years since a landmark Supreme Court decision in 2017 which declared the ban on asylum seekers entering employment was unconstitutional. This paved the way for the enactment of the European Communities (Reception Conditions) Regulations 2018 (Irish Statute Book, 2018), which provides the right to health care, education and access to the labour market alongside other basic human rights. National living standards for those in direct provision were recently published in August 2019 by the Department of Justice and Equality. These identify the need for improvement to the living conditions in Direct Provision Centres and set out a framework to enhance the quality of care provided to refugees, ensuring personal development (Department of Justice and Equality, 2019).

Conclusion

“Nina Cried Power” is a song “intended as a thank you note to the spirit and legacy of protest; to the artists who imbued their work with the vigour of dissent, and a reflection on the importance of that tradition in the context of the rights, and lives, we enjoy today” (Hozier, no date.c). Ireland is reaping the benefits of its development by growing its multicultural society and also welcoming home its emigrants, returning to its shores with new cultural ideals and social norms. This once homogenous and deeply religious country has developed into a cosmopolitan and liberal society. Hozier has used his platform as a popular musician to shine a light on the battles hard fought and won for human rights in Ireland. His video acknowledges the activists whose struggles earned these rights to help shape a kinder and more inclusive Ireland for the benefit of all.

These human rights victories include securing a better Ireland for the LGBT+ community who now have access to equal marriage and gender recognition; reproductive rights for women introduced by way of democratic vote, signalling the healing process of a community who once shamed its women at their most vulnerable; and access to the unknown world of asylum seekers imprisoned in Direct Provision Centres fighting for equal human rights enjoyed by their Irish brothers and sisters. “Nina Cried Power” gives hope and solidarity by reminding us how historic inequality has been overcome. We are reminded, maybe even more importantly, that the struggle for equality and social freedoms in Ireland still continues.

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Midra Shanthikumar

Many people in the Western world are met daily with fundraising campaigns from aid organisations and international non-governmental organisations (INGOs). Images on posters and leaflets, videos, songs and in television advertisements are just some of the ways in which organisations display important issues to convince citizens of the Global North to donate their money. The use of graphic and dramatised images of suffering to generate reactions is sometimes termed ‘poverty pornography’ (Sankore, 2005). Classic images associated with poverty pornography are of ‘starving children with flies around their eyes, too weak to brush them off’ (VSO, 2001). These methods have enabled huge success in fundraising for low and middle-income countries (LMICs) for many years. However, many people question and criticise the portrayal of the Global South through the use of undignified, superficial and disrespectful campaigns. They argue that these campaigns can contribute to stereotypes by providing no context and oversimplifying the issues that people in these countries face (Radi-Aid, 2018) (Kennedy & Hill, 2010).

Orientalism

INGOs and aid organisations have become the leading agencies in representing the Global South and promoting global humanitarianism through the use of media. These campaigns act as a link between the aid recipients and potential donors (Cottle & Nolan, 2007). For some people, these campaigns may be the only insight into the lives of people from the Global South. Radi-Aid is a charity that aims to address concerns surrounding the Western portrayal of Africa through stereotypical, oversimplified and unnuanced aid communication. Radi-Aid and The Norweigan Students’ and Academics’ International Assistance Fund (SAIH) produced a song called ‘Africa for Norway’ (2012), along with a parody video showing Africans appealing for donations of radiators to support the freezing people of Norway. They questioned what people in Africa would think if they were constantly exposed to videos of freezing children in Norway. The video aimed to highlight that aid campaigns provide one-sided representations of Africa and reinforce stereotypes such as Africa being associated with hunger, poverty, crime and AIDS. The video attempted to create a bigger understanding of the detrimental effects of the portrayal of poverty and underdevelopment (Evans, 2013).

The song ‘Africa for Norway’ and the accompanying video resembles popular charity singles such as ‘Do they Know it’s Christmas’ (1984) by Band Aid and ‘We are the World’ (1985) by USA for Africa. Both singles raised money for those affected by the famine in Ethiopia. The lyrics of both the charity songs are controversial as they focus on the idea that the Global North can ‘feed the world’ and can ‘make a brighter day’. These forms of campaigns display the celebrities as compassionate and altruistic but depict people living in Africa as helpless, desperate and reliant on the philanthropy of Westerners. It reinstates colonial ideas of Africa needing to be saved (Müller, 2013). Using such campaigns pushed the focus on the artists and consumer gratification, overlooking the underlying causes of the famine and poverty (Jones, 2017) such as the burden of debt carried by developing countries, ineffective aid and the policies of Western countries in developing countries that create unjust trade relationships (Labonte & Schrecker, 2007). Many aid campaigns explain the suffering as due to bad luck and lack of resources rather than focusing on the economic and political causes for poverty (Hutnyk, 2004). Aid campaigns idealise the effectiveness of aid and oversimplify causes and solutions of development issues in the Global South (Radi-Aid, 2018). The campaigns enforce the idea that money, given philanthropically, can solve issues rather than focusing on long term solutions to underlying issues.

Using culture and marketised philanthropy was effective in encouraging the public to donate money. The USA for Africa single raised more than $60 million (USA for Africa, 2016) and the Band-Aid single raised more than $24 million. As a result of Band Aid, the Live Aid fundraising concerts were held which collected £150 million worldwide, hence making the Band Aid campaign for the Ethiopian famine one of the most successful fundraising campaigns in history (Jones, 2017). The success of these and other similar campaigns highlights how useful they can be in providing aid for international crises. So, to what extent does the oversimplified and stereotypical portrayal of the Global South matter if it is the most effective method to fundraise?

Aid campaigns tend to emphasise the differences between the Global North and South whilst failing to highlight the similarities. This can feed into a narrative that is inaccurate and harmful. Said (1978) referred to this is as ‘Orientalism’, where the West portrays the Global South as backward and uncivilised and in need of guidance and intervention from the West. He argued that by highlighting the differences, it portrays Westerners as superior in comparison to all non-western people and cultures. Orientalism enabled for the Global South to be studied by academics and displayed in museums due to ‘interesting differences’ as well as reconstructed by colonialism due to perceived backwardness.  Furthermore, highlighting the differences between ‘us’ and ‘them’ has encouraged ‘othering’ (Mahadeo & McKinney, 2007). This form of portrayal enabled western oppression and domination of the east for material gain. In the context of aid and as seen in these fundraising campaigns, this form of othering still exists today and continues to deepen the history of Orientalism. It reinforces the power difference between the West and the rest and hides the inequalities that keeps these communities in poverty (Mahadeo & McKinney, 2007).

Studies have shown that aid campaigns have affected public perception by forming negative stereotypes. It builds a sense of superiority of the Global North and inferiority of the Global South (Voluntary Service Overseas, 2001). It depicts the Global South as dependent on Western input and their generous donations, otherwise they are left helpless (Mahadeo & McKinney, 2007). Voluntary Service Overseas (VSO) (2001) conducted a poll using 1018 British participants. They found that 80% associated the developing world with famine, war, debt, starvation, poverty, corruption, natural disaster and Western aid. 74% believed that countries of the developing world rely on funding and knowledge from the West to progress. Efforts should be made to prevent reinforcement of these harmful stereotypes. It negates the progression that has been occurring within countries in Africa. Between 2000 and 2010, six out of the ten countries with the highest economic growth were in Africa (Evans, 2013). Furthermore, Evans (2013) argued that by repeatedly displaying Africa as a continent that is ‘homogenously poor’, dependent, lacking in financial security and ability to generate profit is unfair and harmful. These negative misconceptions may deter potential investors as financial security and profit are key incentives. The lack of financial investment can further contribute to underdevelopment and hinder the chances of overcoming poverty (Evans, 2013).

Human rights

The work of Band Aid was criticised due to their use of graphic images of starving African children to capture attention, however, the Band-Aid campaign was certainly not the first or last to use this approach. The graphic images used by Band Aid during the period of the Ethiopian famine maintained interest, heightened emotions and increased generosity; just under £100 million was donated by the British public to various charities specifically for Ethiopian famine relief between April 1984 and September 1985. The increase in income allowed aid organisations to grow by increasing their budgets and workforce and invest money in marketing and administration (Jones, 2017). Due to the success of gripping images in capturing attention and encouraging public donations, many NGOs continue to use graphic images.

However, the pressing issue with the use of graphic images is the lack of human dignity and respect and violation of human rights. The use of images of those that are suffering can be unethical if the people are not fairly represented and there is no story behind the picture to provide context (Young, 2012). A survey by Oxfam UK (2012) found that the public seemed to be de-sensitised to pictures of poverty. As shown by the success of such campaigns, they succeed in invoking a sense of sympathy however, once the image is taken away, people forget. The continued use of images of suffering along with no signs of improvement can discourage the public from donating to campaigns that seem to make no difference (Evans, 2013).

Figure 1: Graphic images used in the Band-Aid single video, ‘Do they Know it’s Christmas’

What is the solution?

Repeatedly representing the Global South, particularly Africa, with the same ‘single story’ in aid campaigns has no benefits in the long term. Giving money philanthropically does not alter the structural problems such as unfair trade relationships that keep Africans poor. Additionally, the presentation of Africa as characterised solely by war, famine and poverty is grossly misleading. Many people on social media, such as Twitter and Instagram, have posted pictures under the hashtag #TheAfricaTheMediaNeverShowsYou to show the huge diversity of the African continent. The twenty-first century has seen the introduction of deliberate positivity whereby organisations are beginning to rely on images depicting hope, progress and self-reliance (Nathanson, 2013). However, the use of positive images in campaigns has been criticised for emphasising the dependence of aid recipients on donations from the Global North (Orgad, 2013). Furthermore, negative images have shown to be the most effective in generating donations (Erlandsson, Nilsson & Västfjäll, 2018). This confirms the complexity of aid communication as using both positive and negative images introduce ethical problems.

Understandably, it can be hard for these organisations to provide context and convey the complexity of development issues simply so that the public can understand. Evans (2013) argues that once the organisation has captured the attention of the viewer, they should take the opportunity to display the bigger picture. However, these issues are very complex and almost impossible to explain within a poster or advert. Sometimes, information cannot be shared due to the sensitivity of the topic as it can put people and the work of the NGO at risk (Macrae, 2000). Some charities use personal stories of those living in developing countries in the hope it provides context and encourages donations (Nathanson, 2013). The challenge remains with educating the Western public of the political factors that cause poverty and prevent change (Dolinar & Sitar, 2013).

Radi-Aid have released recommendations regarding fundraising campaigns after conducting focus groups with people from developing countries to understand their opinions on aid campaigns. They found varied responses confirming the complexity of aid communication. Most understood that negative images were used to prompt an emotional reaction that encouraged donations. However, many respondents highlighted the importance of maintaining the dignity of the individuals who are portrayed, considering all persons’ human rights, ensuring they have given consent and ensure all persons are represented fairly in a balanced manner (Radi-Aid, 2018). This is vital to prevent reinforcement of negative stereotypes, prevent oversimplification of the issues that are faced and maintain the dignity of people being displayed. Providing a balanced representation can also show that donations make a difference and therefore may encourage people to donate (Warrington & Crombie, 2017). ChildHope (2016) has stated that campaigners should allow those that are portrayed to share their preferences regarding their representation. They have since released consent forms for photographers working for their organisation to retrieve from children and their guardians when taking images to be used in campaigns.

The portrayal of the Global South in charity appeals is a complex issue that does not seem to have a clear solution. Ethical methods, for instance, through positive images of hope and progress are less likely to generate the emotional response that frequently motivates donation. The solution seems to lie within educating the public to understand development to prevent stereotypes through the use of balanced portrayal. This perhaps can be done through the use of stories whilst ensuring that the dignity and the rights of those in the Global South are upheld.

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Esther Blakey

Voluntourism, defined as tourists partaking in organized volunteer work whilst travelling abroad, sees 1.6 million predominantly Global North voluntourists travel to the Global South each year (Bandyopadhyay & Patil, 2017). Voluntourism programmes typically combine short-term voluntary activities that require little or no training designed to relieve material poverty in host destinations, with traditional tourist travel and leisure experiences (APEC, 2018). Voluntourism is subject both to praise – with volunteers providing valuable services to host communities and exposure to important global issues – and to criticism, given the accusations of selfishly-driven volunteers and concerns regarding exploitation of host communities (Hernandez-Maskivker, Lapointe and Aquino, 2018). In this blog, I explore the evidence on both sides of this debate.

Volunteers

Existing literature on voluntourism emphasizes the transformative experiences of volunteers. Bandyopadhyay (2019) describes how volunteering can lead to self-growth and sense of purpose by enabling volunteers to contribute to something they believe actually matters. By combining volunteering with tourist activities, voluntourism also enables volunteers to fulfill personal desires for adventure and travel. McLennan (2019) found that volunteers valued the travel experience offered by voluntourism programmes compared to traditional tourism, perceiving working with host communities as providing a more authentic insight into the ‘real’ local culture. Wearing and McGehee (2013) describe how this engagement in host communities benefits volunteers by altering their world view and enhancing their notion of self through greater personal reflection. Volunteering is also an effective way for tourists to develop their CVs by demonstrating that they are active global citizens, potentially leading to career advancements (McLennan, 2019; Wright, 2013). Indeed, despite these self-benefits, Wright (2013) found that most tourists consider volunteering to be a predominantly altruistic activity, benefiting hosts more than volunteers. Critics however accuse tourists of selfishly combining leisure with charity, with the ego-enhancing, self-benefiting rewards ultimately trumping any altruistic intentions of helping others (Hernandez-Maskivker, Lapointe and Aquino, 2018).

Host Communities

Voluntourists, who are invariably equipped with ample spending money, generate an estimated $2 billion annual revenue for the Global South economy (Bandyopadhyay and Patil, 2017).  This can support local businesses and create employment opportunities. In addition, volunteers provide free labour for sustainable development projects (Hernandez-Maskivker, Lapointe and Aquino, 2018). On the other hand, by acting as free labourers, volunteers can decrease local employment, which can lead to host dependency on volunteers. Voluntourism can also place excessive demand on important resources like drinking water, energy and food, depriving locals of finite resources (Hernandez-Maskivker, Lapointe and Aquino, 2018).

Collaborating with volunteers facilitates cross‐cultural interactions that can foster mutual understanding and relationships between hosts and volunteers, and enable hosts to learn about other cultures whilst sharing their own (Hernandez-Maskivker et al., 2018 ; Wright, 2013). Conversely voluntourism may damage local culture as large influxes of volunteers can lead to the deterioration of sacred places, damage to fragile ecosystems and the introduction of harmful practices such as consumption of alcohol and drugs. Changes to employment opportunities can also weaken a destination’s economic autonomy by diminishing traditional economic activities.

Host communities face complex problems. Hernandez-Maskivker, Lapointe and Aquino (2018) argue that due to a lack of skills and knowledge, volunteers can only help with superficial issues thereby limiting their contributions to host communities. Many organisations do not require volunteers to have skills specific to the work they travel to perform, often resulting in poor quality labour. For example, the continuous turnover of short-term, untrained volunteers teaching in schools can lead to a loss of structure and direction of education (Wright, 2013). It could be argued therefore that volunteers are an overall hindrance and that resources would be better utilised supporting locals to carry out the tourists’ work.

Likewise, reports of volunteer-run orphanages fuelling child trafficking and abuse introduce an increasingly concerning ‘dark side’ of voluntourism (Friends-International., 2018). Many volunteering agencies do not carry out safety checks on tourists, meaning unchecked volunteers could pose huge child protection risks (ReThink Orphanages, 2018b). Even well-meaning volunteers can negatively impact children’s psychosocial development being ill-equipped to meet the needs of children requiring specialized support and care. The constant turnover of short-stay volunteers creates a cycle of connection and abandonment for the children, leading to attachment disorders and low self-esteem (ReThink Orphanages, 2018b).  An estimated 80% of children in volunteer-run orphanages have at least one living parent and are frequently orphaned as a result of poverty rather than parental death. Profiting from volunteers encourages orphanages to ‘recruit’ children unnecessarily and reduces incentives to support families in poverty to care for children at home (ReThink Orphanages, 2018b).  

The benefits of voluntourism for volunteers are clear. The benefits to the host, however, are questionable, and accompanied with serious potential for harm. Tourists, seeing voluntourism as predominantly positive and altruistic, appear largely unaware of its more ambiguous impacts on host communities (Wright, 2013). Considering this, I will now discuss the origins of this discrepancy in perceived benefit of voluntourism.

The Industry

Voluntourism organizations specialize in recruiting mainly young, Global North tourists (Bandyopadhyay and Patil, 2017).  Quotes taken directly from Globe Aware’s website read ‘Come and fight poverty in India and enhance the lives of poverty-stricken children in ways that you can only begin to imagine’ and, even more shockingly ‘ Instead of going to a local spa with your girlfriends why not experience a fish pedicure in Cambodia …[and]… make an impact by assembling wheelchairs for landmine victims?’’ (Globe Aware 2019). These examples demonstrate how voluntourism organisations sell the idea of ‘saving the helpless’ to impressionable young people. By bombarding potential tourists with a ‘white saviour’ narrative, similar organisations, in addition to mainstream and social media, romanticise voluntourism and give an unrealistic, idealistic impression of its positive impact (Wright, 2013).

Said’s work on Orientalism describes how during colonial times, false, romanticised myths and travellers’ tales formed and justified the western understanding and ‘othering’ of the ‘Rest’, facilitating the colonial ideology of the ‘West’ ‘improving’ the ‘Rest’ (Hall & Gieben, 2013). Bandyopadhya & Patil (2017) argue that voluntourism inherits such colonialist distinctions by portraying Global South as ‘childlike’, awaiting western assistance, regardless of whether people or governments in the Global South want or request help or not.  They argue that Global North tourists seeking to ‘save’ the Global South is akin to neo-colonialism, propagating unequal power relationships and the rhetoric that the ‘West knows best’. An article by Teju Cole (2012) highlights how this ‘white saviour’ narrative disregards the agency and autonomy of developing countries and their citizens to develop their own countries and direct their own social and political transformations (Gulrajani, 2011). 

Images of the needy developing world and the apparent benefits of voluntourism projects are recorded as central motivators for potential tourists (Freidus, 2017).  I argue that by romanticising and exaggerating the impacts of voluntourism the industry is responsible for perpetuating harmful stereotypes to profit from well-meaning, naive volunteers.

The Future of Voluntourism

In a world where it is increasingly important to challenge the dominant ways of defining North-South relations, understanding the meanings of voluntourism within a broader history of colonial thought and acting accordingly is vital to avoid contributing to the western paternalism that has driven development for so long (Bandyopadhyay and Patil, 2017). It is imperative to ensure responsible marketing within the voluntourism sector, to ensure that tourists know what they are signing up for and that hosts are aware of the industry they are entering (Wright, 2013). Rather than perpetuating the neocolonialist ‘white saviour’ narrative, there should be a greater focus on working as a team, involving hosts in the planning and management of projects to empower communities and maximize host benefits (Wright, 2013).

The role of the tourist is contentious. Despite the obvious problems with voluntourism, the transformative experiences for some tourists cannot be overlooked. It is also It is unlikely that, without the opportunity of travelling abroad, young people would donate the funds they work hard to raise for their trips.  Rather than losing this income by discouraging volunteering I argue that tourists should be educated on the realities of voluntourism to better inform the type of voluntourism they choose to support.

An excerpt from Lonely Planet’s guide on voluntourism reads:

‘Whether international volunteering is the new colonialism or not is, in large part, down to the attitudes of you, the volunteer, and the organization you go with. If you don’t want to be a 21st century colonialist, rule out organizations that suggest you’ll be “saving the world” or give a patronizing image of the developing world…question yourself. Be open about why you want to be an international volunteer …. Avoiding being a New Age colonialist will take some effort and research’ (Bandyopadhyay, 2019).

Whilst the industry will likely be slow to change, potential tourists can be empowered through education to support responsible, ethical organizations.

The appropriate training and recruitment of skilled volunteers should be prioritized to avoid tourists taking on roles for which they are unqualified. In addition, there is currently no overall regulatory framework for safety-checking volunteers for the industry to comply with (Friends-International., 2018).  Although important in all areas of voluntourism, this is especially relevant to child or education-based placements where unchecked and untrained volunteers can negatively impact children’s education, development and safety. Legal guidelines surrounding the training and safety-checking of tourists need to be properly implemented.  

With voluntourism encouraging the unnecessary orphaning and poor care of children, there is growing support to end orphanage tourism (ReThink Orphanages, 2018a). Organizations including ReThink Orphanages, Friends International and Lumos are campaigning to raise awareness of the harmful practices surrounding orphanages to discourage tourists and shift the focus towards supporting families to keep children at home (Figure 2).

Existing literature on voluntourism focuses largely on the tourist’s perspective, whilst research into how voluntourism impacts host communities and how to maximize long-term benefits and avoid harm is desperately lacking. Additionally, as most voluntourism organisations are western owned and their objectives and outcomes correspondingly measured according to western ideals (which may differ to the social, political and economic norms or aspirations of host communities), one must treat existing literature with caution (Wright, 2013).  In spite of this, Hernandez-Maskivker, Lapointe and Aquino (2018) argue that voluntourism can bring long‐term benefits if done responsibly and sustainably. Future research should therefore focus on host communities to ensure that the profits of this lucrative industry are channeled into long-term benefits for them.

Final thoughts

I do not believe that voluntourism is inherently wrong. There is, however, an obvious need for a change in the current industry. I argue that rather than criticizing the naivety of many tourists, focus should instead be on encouraging responsible marketing by voluntourism agencies and the education of potential tourists on the true reality of the industry. Ultimately, maximizing benefit and avoiding harm to host communities should be the primary goal of all parties participating in voluntourism.

Bibliography

APEC (2018) Voluntourism Best Practices: Promoting Inclusive Community-Based Sustainable Tourism Initiatives. Asia-Pacific Economic Cooperation Secretariat 0-61

Bandyopadhyay, R. (2019). Volunteer tourism and “The White Man’s Burden”: globalization of suffering, white savior complex, religion and modernity. Journal of Sustainable Tourism, 27(3), 327–343

Bandyopadhyay, R & Patil, V. (2017). ‘The white woman’s burden’, the racialized, gendered politics of volunteer tourism. Tourism Geographies 2017, 19(4), 644-657.

Friends-International (2018). Voluntourism & Orphanages, Challenges Remain. Retrieved 16/11,2019 from https://friends-international.org/blog/index.php/orphanages-voluntourism-challenges-remain/

Globe Aware (2019). Girl Getaways. Retrieved 01/11, 2019, from https://globeaware.org/volunteers/girl-getaways

Globe Aware. (2019). India.  Retrieved 01/11, 2019, from https://globeaware.org/about-us/make-a-difference-make-an-impact/item/117088-india

Hall, S & Gieben, B. (2013) Formations of modernity. Cambridge: Polity in association with the Open University.

Hernandez-Maskivker, G., Lapointe, D., & Aquino, R. (2018). The impact of volunteer tourism on local communities: A managerial perspective. International Journal of Tourism Research, 20(5), 650–659

McLennan S J. (2019). Global encounters: Voluntourism, development and global citizenship in Fiji. The Geographical Journal, 185(3):338–51.

ReThink Orphanages (2018a). Facts And Figures About Orphanage Tourism. Retrieved 15/11/2019 from https://rethinkorphanages.org/problem-orphanages/facts-and-figures-about-orphanage-tourism

ReThink Orphanages (2018b). Orphanage Volunteering: Can I Volunteer At An Orphanage Abroad? Retrieved 15/11/2019 from https://rethinkorphanages.org/rethinkorphanages.org/problem-with-orphanage-tourism_volunteering

Sin, L. H., & He, S. (2015). Voluntouring on Facebook and Instagram: Photography and social media in constructing the ‘Third World’ experience. Tourist Studies. 19(2), 215–237.

Cole, T. (2012). The White-Savior Industrial Complex. Retrieved 15/11. 2019 from https://www.theatlantic.com/international/archive/2012/03/the-white-savior-industrial-complex/254843/.

Wearing, S and McGehee, N G. (2013). Volunteer tourism: A review. Tourism management. 38(1), 120-130.

Wright, H. (2013). Volunteer tourism and its (mis)perceptions: A comparative analysis of tourist/host perceptions. Tourism and Hospitality Research, 13(4), 239–250.

by Rachil Emmanouel

The NHS, which this year celebrated its 70^th anniversary, was described by its founding father, Aneurin Bevan as “the most civilised step any country has taken”. It emerged as one of the pillars of the welfare state in the aftermath of the Second World War, in an era when social democratic sentiments and demands for a more egalitarian distribution of resources were captivating the nation. Today, the NHS remains an object of veneration and arguably the most cherished institution in the country. It offers universal, comprehensive and free healthcare from cradle to grave and has liberated citizens from the financial burdens of illness that were characteristic of the pre-war era. However, unbeknown to large swathes of the general public, the NHS has, over the past 30 years, been subjected to a series of reforms that threaten its founding principles. These reforms have been driven by neoliberal ideology and health industry lobbying, with the aim of transforming healthcare from a public good into a profitable commodity. The incremental changes that have been introduced by successive governments are often packaged and sold to the public under more palatable terms, with which we have all become too familiar: efficiency, patient-choice and modernisation. On closer inspection, however, the reality which emerges is characterised by unprecedented cuts, job losses and the liberation of the NHS budget to corporate sectors which are unaccountable and place profit above people’s wellbeing.

The basis of neoliberalism

In response to the global economic stagnation in the 1970s, the world witnessed an emphatic turn towards the adoption of neoliberal principles spearheaded by the Thatcher and Reagan regimes in Britain and the United States (Harvey, 2007). In essence, the central features of neoliberal ideology promote the shrinking of the state, privatisation of public services and industries, and deregulation of banks. In Britain this has translated into the gradual erosion of public institutions which were previously regarded as being immune from private profiteering such as education, public housing and indeed healthcare. At its crux, the neoliberal position favours market-led over state-led approaches. The underpinning assumption is that state-run institutions are inadequate, inefficient, bureaucratic and of a low standard. Private sector involvement, on the other hand, is highly regarded as being efficient and innovative. Under neoliberal thought, business logistics and corporate management are to be adopted by the rudimentary public sector in order to generate efficiency and results.

Marketising the NHS

Neoliberal rhetoric has seeped into policy making pertaining to the NHS. Successive governments, both Labour and Conservative, have adopted policies favouring the restructuring of the organisation into a market-model and the shrinking of the state through austerity measures (Leys, 2017). The process of marketisation has been insidious and began with the creation of the internal market in the 1980s under John Major. This was a system of NHS hospital trusts (providers of services) and Primary Care Trusts (purchasers of services) where hospitals compete to secure business. To fit a business model, their income was related to performance by the introduction of payment by results, whereby every completed treatment was assigned a fixed price according to its cost and risk. Despite assertions that the marketization project would reduce bureaucracy and costs, the reforms have in fact achieved the opposite. A 2005 study found that £10 billion, which is 10% of the NHS budget, is spent annually on running the internal market (Bloor et al, 2005). The costs are accrued from the billing of treatments, formulation of contracts, litigation and the salaries of an ever-increasing number of senior managers, lawyers, HR and IT staff recruited to run the market’s infrastructure.

Under New Labour the NHS Plan 2000 and NHS Improvement Plan 2004 served to open up this internal market to commercial interests as the private sector was allowed to enter the bid for NHS contracts and compete with NHS hospital trusts. Again, the reforms were premised on the notion that these Public-Private-Partnerships would promote innovation, efficiency and ease pressure on cash-strapped NHS trusts. The reality however has turned out rather differently. Schemes such as the Independent Sector Treatment Centres (ISTCs) have seen private companies, equipped with financial and legal might, outcompeting NHS trusts for high-volume, low risk, lucrative NHS contracts such as cataract removals and hip replacements. Meanwhile, NHS trusts are left with the double-burden of losing out on high-income procedures whilst being left to pay for less-profitable ones, such as treatments in emergency care (El-Gingihy, 2018). Furthermore, findings by the British Medical Association reveal that, in an attempt to attract private investment ISTC contracts cost on average 12% more than NHS tariffs and private providers are often paid in advance for a pre-determined number of cases, regardless of whether or not treatments are actually completed (Ruane, 2016). One astonishing example is that of the private contractor, Netcare, which performed a meagre 40% of contracted procedures, whilst receiving £35 million for patients it never treated (Pollock, 2014). Although clearly fraudulent, such anecdotes hardly come as a surprise given that private companies are primarily accountable to their shareholders and have a duty to make profits.

The notion that a healthcare system can be run successfully under a business model is fundamentally flawed, namely because the private sector’s dogma of cost-cutting and efficiency is irreconcilable with good patient care. Unlike in other industries, the principle of efficiency cuts to improve productivity does not apply in the healthcare industry. Its reliance on highly-skilled labour and continual development of new treatments coupled with the realities of an increasing demand for healthcare services from an ageing population means that it cannot fit the business model, which strives for increased output with reduced investment. Adherence to the ‘efficiency’ principle within the NHS has underpinned decisions to reduce staffing-levels across trusts, restrict access to health services, make pay cuts and compromises in quality of care.

Perhaps one of the worst examples of this comes from the catastrophic failure at Hinchingbrooke Hospital in Cambridgeshire, the first NHS hospital to be transferred to a private management firm (Cooper, 2015). Circle Health won the contract having promised to use its business acumen to improve the hospital’s performance but the reality stood in stark contrast to these pledges. Between 2012 to 2015, the hospital’s deficit doubled. In an effort to curb costs, Circle Health’s management hollowed out quality of care to the point where the CQC put the hospital under ‘special measures’ for its inadequate safety performance. After just three years, the firm abandoned the contract leaving the hospital £9 million in deficit, which excluded additional litigation costs – all of which were to be covered by the NHS. The reality of private sector involvement in the NHS has thus been the privatisation of profits and socialisation of harm, whereby private firms are not held accountable for their failures and the British taxpayer is ultimately made to rectify the consequences.

Privatising politics

Despite the failures of the marketisation project in the NHS, the British government today continues to award large contracts to the private healthcare industry whilst simultaneously imposing austerity measures on the NHS budget. Meanwhile, recent data from the British Social Attitudes research centre has revealed that 61% of people were willing to pay more tax to fund the health service (The King’s Fund, 2018). What is clear is that the neoliberal reforms of the NHS over the past several decades have been passed without popular support or a democratic mandate. Colin Leys, co-author of The Plot Against the NHS, argues that changes have been made covertly with their true intentions deliberately concealed (Leys and Player, 2011). How this gradual dismantling of the NHS, and indeed other public assets, has been achieved points to the wider issue of how the democratic process has been hijacked in the neoliberal age. Implicated in this process is the media and its role in propagating and failing to critically challenge government spin. More crucially, British politics itself has been privatised and bent towards the interests of private corporations. There exists between the government and the private health industry a ‘revolving door’, which serves as a means by which politicians can leave office and become well-paid lobbyists for large corporations and vice versa (Cave & Rowell, 2014). For example, Simon Stevens, the current Chief Executive of NHS England and architect of many recent NHS reforms, was also the former president of United Health Global – one of the biggest American private insurers, which has been implicated in countless scandals and lawsuits. Political decisions are mired by conflicts of interest as politicians’ loyalties lie not with the general public but their financiers. The stronghold private corporations possess over the political process has also been demonstrated in cases where the government has acted against private sector interests. In a recent example, Virgin successfully sued the NHS £2 million as compensation for not being awarded a contract to deliver care in Surrey (NHE, 2018). In this sense, it can be seen how the private sector adopts a carrot-and-stick approach to securing its interests.

Neoliberalism: a means to restore class power?

David Harvey (2007) asserts that neoliberalism has been a “project to restore class dominance to sectors that saw their fortunes threatened by the ascent of social democratic endeavours in the aftermath of the Second World War”. Using only the example of Britain’s National Health Service and how it has been subjected to a series of neoliberal reforms that have led to the increasing commodification of healthcare, Harvey’s position appears rather plausible. The British public’s unwavering desire to maintain the NHS as a universal service, free at the point of use, is perhaps the most powerful bastion against an extensive, US-style private healthcare system. As Aneurin Bevan himself once wrote, the NHS will last as long as there are folk to fight for it.