The Human Development Approach to Women's Health in Yemen
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THE HUMAN DEVELOPMENT APPROACH TO WOMEN’S HEALTH IN YEMEN Simone Wahnschafft Yemen, a nation that has been classified by the United Nations as one of the Least Developed Countries (LDCs) since the 1970s, has long been characterized by inaccessible healthcare for the majority of its population. Although Yemen has a largely rural population – roughly 65% in 2015 – most healthcare facilities have historically been concentrated in urban areas (2-3). An overdependence on these fixed healthcare sites in urban centers has resulted in an inefficient allocation of healthcare workers (HCWs), where many HCWs will see as few as one to three patients in a single day despite millions of people in need of healthcare (4). Yemen has had very poor health outcomes as a result of such deficiencies in healthcare infrastructure, including a very high prevalence of malnutrition and under five child mortality rate (5). These factors are heavily entwined, where the cause of many of Yemen’s health problems ties back to one population – women. The most recent Millenium Development Goals (MDG) progress report on Yemen explains that while developmental support for reducing child mortality was “fair,” the persistent lack of improvement in the under five child mortality rate was primarily due to undernourished and overall unhealthy mothers. Yemen’s Maternal Mortality Rate (MMR) has historically been very high: approximately 1 in 39 Yemeni women die during childbirth (7). The MDG progress report indicated that the Yemeni MMR had not been improved since 1997 (5). Besides structural inefficiencies in the health care system itself, the poor health outcomes for both women and children in Yemen are rooted in the lack of opportunities that are afforded to women by Yemeni social structure. In 2014, the average cutoff for women’s education stood at a mere 7 years and women’s literacy rate at 60% that of male’s (7). Furthermore, child marriage is often practiced in Yemen, where nearly half of all Yemeni girls are married by age 17 (8). Practices such as child marriage are directly responsible for not only poor health outcomes for women, but also for the high birth rate, population growth, and child mortality and morbidity rates (8). 2 Although significant improvements in women’s social opportunities or health outcomes have not yet manifested in Yemen, targeting women’s health has been a long term goal for both the Yemeni government and the international aid community. For instance, in 2011, the Ministry of Population and Public Health published the “Yemen National Reproductive Health Strategy 2011- 2015,” which included extensive proposed measures for targeting reproductive health across the country (9). On the international level, several programs were implemented to address social opportunities for women in Yemen, including the “Safe Age of Marriage” program that was implemented by USAID to increase awareness in rural communities of the harms of child marriage for Yemeni girls (8). The MDG report reflected the burgeoning focus on women’s opportunities as well as the promise of these developing programs, describing the supportive environment of gender equality in Yemen as “weak but improving” (5). The outbreak of civil war this past spring, however, has resulted in growing strains on Yemen’s healthcare system that have shifted governmental and international aid focus away from social programs for addressing women. Yemen has increasingly come to face a wide variety of public health threats, such as a dire water shortage and the growing vulnerability to the outbreak of infectious disease (1). Military tactics employed by a Saudi Arabia-led coalition that target healthcare infrastructure, such as the bombing of healthcare facilities and the imposition of an air and sea blockade have hampered international aid efforts (1). The conflict has ultimately placed further strain on already limited health resources and has raised new considerations regarding distributive justice – the socially just allocation of resources in a society. Alex John London, in his piece “Justice and the Human Development Approach to International Research,” presents a compelling approach for addressing concerns of distributive justice. In his human development approach, London poses two overarching questions to assess both the health needs and socially just health interventions for a developing nation. These questions 3 are difficult to disentangle from the context of the article itself, as London uses them to address the ethics of international research in particular. But at their heart, these questions are fundamental to determining a just allocation of resources. The first question addresses the role of social structures, primarily cultural, governmental, and health institutions, as the most important determinants of health. For this question, London establishes the social conditions under which a community has an entitlement under a strict obligation of justice to receive intervention for improvement of their condition. The second question then turns to the assessment of who holds the obligation to address these issues. The remainder of this paper applies this human development approach to assess the extent to which focusing on women’s health is a socially just and effective long term goal for Yemen in the face of continued political conflict. The first question of the human development framework evaluates the allotment of resources that a community is entitled to in the context of developing nations where resources are scarce. Essentially, this entitlement depends on the ability of the community’s social structure to function towards the common good by providing “each person an effective opportunity to cultivate and use their basic intellectual, affective and social capacities to pursue a meaningful life plan” (11). London argues that it is when social structures fail to allocate resource towards serving the common good that individuals suffer negative health repercussions. Social structure has a profound effect on women in health. Because of cultural factors, women are not afforded the same rights to education and social development as males in Yemeni society. The social inequality that women face in Yemen is directly correlated with both poorer health outcomes, evident in Yemen’s high maternal mortality and morbidity rates, as well as increased barriers to healthcare. Cultural values in Yemen often mean that women must be accompanied to health facilities by a male chaperone or are only able to be seen by a female health worker (4). Women are a clear example of a population within Yemeni social structure that is not afforded the opportunity to cultivate their own basic capabilities. 4 According to London, in a situation where social structure is not conducive to the development of individual capabilities, health-related institutions can mitigate the situation by targeting the social determinants of health, such as education, in order to facilitate human development. Therefore, the consideration of social context under human development approach establishes women as a population whose development should be a fundamental goal for health-institutions in Yemen. However, a complete understanding of the extent of this goal and the allocation towards women’s opportunities must also take into account the current context of war. As briefly touched upon earlier in this paper, the conflict in Yemen has exacerbated emergency problems such as an acute water shortage, where an estimated 50% of Yemen’s population struggles to find water on a daily basis (10). Malnutrition prevalence, which stood at 48% of the population before the war, has risen an approximate 20% as a result of the war (12). The WHO estimates that millions of people are left to die in their homes because they are not able to receive treatment due to the constant fighting (1). While these emergency situations would seem to minimize the importance of investing in women’s development and emphasize an increased focus on these immediate concerns, a consideration of the social context under the human development view actually highlights the importance of women’s health. While the water shortage and high malnutrition rates were surely exacerbated by the blockade, they were both significant national health issues before the escalation of conflict and are more a consequence of Yemen’s rapid population growth than of the effects of war (13). As discussed earlier in this paper, population growth in Yemen is heavily correlated with women’s social opportunities, as child marriage has resulted in Yemen having one of the highest birth rates in the world where the average Yemeni women has 7 children (5). Thus, the development of women’s basic opportunities in Yemeni society is both a just allocation of resources and an effective strategy for long term health improvement even in the face of continued political conflict. 5 Having established the obligation and importance of focusing on women’s development in Yemen, the question then becomes, who is obligated to address this issue? For this question, London grounds this obligation in the idea of rectification, where developed nations who have contributed to the plight of the members of the developing community have a special duty to aid that population. In the context of the current Yemen crisis, the human development approach points to a special responsibility of the United States government to provide resources to mitigate the humanitarian crisis, as the U.S. logistical support of the Saudi Arabia-led coalition has played a significant role in the impending healthcare system collapse in Yemen (14). It is less certain under the criteria of rectification, however, whether the United States has a direct responsibility to allocate resources specifically to women’s social opportunities. However, London furthers his argument regarding the obligation to aid to a broader basis of social justice, where those in the developed world have a responsibility to aid conditions of “social deprivation” in the developing world (11). He elaborates that those with a duty to provide aid, such as the U.S.