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This material is reproduced with permission from the copyright holder. Please cite as (1998) 4 Health and Human Rights 315-348

Lynn P. Freedman, JD, MPH

Public health and human rights are "powerful, modern approaches to defining and advancing human well-being" ¹ and so are potentially powerful tools for generating change. Yet public health and human rights have also, at times, been powerful tools for maintaining the status quo, reinforcing hierarchies of power and domination based on race, gender, and class. Thus, just because a concern or policy or program adopts the label "health" or "human rights" does not give it unqualified value. To create a workable framework for health and human rights collaboration, we need first to define human well-being; only then will it be possible to clarify how the tools of public health and human rights can be used to advance that vision of it.

Of course, defining human well-being is a rather tall order, which I don't pretend to fill in these few pages. My aim is much more modest: in these reflections I try to expose some of the assumptions about human well-being that underlie traditional views o£ public health, human rights, and

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the connections between them, and to suggest some possible alternative directions for future discussion, elaboration, and action. In doing so, I write primarily from my perspective as a women's health advocate with a focus on reproductive health and reproductive rights. My approach is shaped not only by my academic training (in law and public health), but also by my engagement with the fields traditionally described as population, family planning, maternal/child health, women's rights, and human rights, and by my understanding of the forces that have historically driven programs, policies, and scholarship in those fields.

Perhaps because of this background and orientation, I view health and human rights advocacy as an essentially subversive activity, in the sense that my vision of "defining and advancing human well-being" ultimately requires overturning deeply-rooted social and political structures that produce ill health and that prevent all people-women and men from fulfilling their highest potential as human beings. But the goal is not to destroy: it is to transform and create. The structures that now obstruct human well-being must be changed into modes of social organization and interaction that will promote and support it. The disciplines of public health and human rights offer ways of thinking, of working, and of organizing that can ultimately give expression and concrete direction to that endeavor.

Public health is a quintessentially social enterprise. Whereas medicine looks at the biological mechanisms of disease in individual people, public health looks at patterns of health and disease in populations. Most critical for present purposes, public health focuses on the links between an individual and the environment (physical, social, cultural, political, and/or economic) in which she lives, seeking in that linkage both an explanation for her health status and a potential entry point for policies and programs to address it.

The primary research and analytical tool of public health is epidemiology. Using statistics and probability theory, epidemiologists document a particular health phenomenon (e.g., maternal death) and measure the strength of its association

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with particular "risk factors" (e.g., maternal age or parity). Through this measurement, epidemiologists quantify risk; they measure the probability that a particular health phenomenon will occur if a particular risk factor is present. When a sufficient likelihood of an association is repeatedly found, the epidemiologist can state with reasonable confidence that the association is "real," i.e., it is not due to chance, bias, or poor study design. From such an association between a phenomenon and a risk factor, as well as additional information, the epidemiologist can infer-not prove-causality. That understanding of possible causal relationships can then form the basis for making effective public health policies and programs.

To many activists this may sound like a dry and tedious exercise, but in fact it has truly revolutionary potential. Nancy Krieger, in an insightful article about the politics of public health data,² tells the story of how Louis René Villermé (1782-1863), one of the founders of epidemiology, used his classic study of mortality in early 19th century Paris to challenge theories of disease causation that had prevailed in European medical thought for nearly 2000 years. In this study, Villermé first documented and ranked variations in mortality rates across different neighborhoods in Paris. He then attempted to correlate the variation in mortality with variations in environmental factors such as altitude, seasonal temperature, humidity, and quality of air, water, and soil, all of which were thought to cause disease. In this first ever systematic test of long-accepted environmental theories of disease causation, it turned out that none of these factors could account for the differences in mortality rates.

Looking for an alternative explanation, Villermé turned to the field of sociology, just then emerging in Europe, to develop hypotheses about the effects of social factors such as poverty and wealth on health. This time he calculated the proportion of households in each neighborhood that were exempt from rent tax, which was levied only on the wealthy, in order to arrive at a proxy measurement for poverty. He then correlated those proportions with the mortality data. The result was an "almost perfect fit": the neighborhoods with the lowest mortality also had the lowest pro

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portion of tax-exempt households (i.e., were the wealthiest), while the neighborhoods with the highest mortality rates had the highest portion of tax-exempt households (i.e., were the poorest).³ Villermé thus concluded that social factors such as wealth and poverty (factors amenable to manipulation through public policy) were the principal causes of wide variations in mortality-a conclusion that, as Krieger pointedly notes, was not unrelated to the politics of his own time and place:

Villerme's study is a classic example of the basic methodology employed by epidemiologists; it also helps demonstrate several points that are key to this discussion about the potential for health and human rights collaboration. As Krieger points out, Villerme's important findings about the nature of disease, "did not depend on technological or bio-medical breakthroughs, but upon broadening the 'natura' discourse of science with explicitly political concepts."⁵ Moreover, I would add, what was (and is) uncritically accepted in science as "natural" and therefore immutable, has often served as effective camouflage for those in power to promote their own social and political goals-a phenomenon repeatedly uncovered in the histories of medical and "scientific" approaches to women's reproduction,⁶ to racial differences,⁷

and to colonial health policy.⁸

The influence of political ideology on health research and policymaking is fairly easy to see and accept in historical studies, especially with the benefit of nearly two centuries of hindsight, as in the example of Villerme. It is far more difficult to recognize and expose such assumptions when they are embedded in the daily discourse and routine work of public health today. To illustrate how politically or culturally

conditioned assumptions about women's roles and lives influence current public health research and practice, I exam-

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ine one article from the growing literature on the health effects of structural adjustment programs.

In an essay entitled "A Public Health Approach to the 'Food-Malnutrition-Economic Recession Complex,"'9 Leonardo Mata challenges the contention that shrinking food availability caused by economic crisis has led to declining child health. He questions whether economic conditions have significantly changed the "nutritional state and survival of children in less developed countries" because, in fact, the unavailability of food is not the usual cause of malnutrition and infant/child death. He demonstrates that infant and child mortality in developing countries is more often a complex interaction between malnutrition and infection conditioned by a multitude of factors other than the mere lack of food.

Mata then points to the fact that, given precisely the same financial resources and physical environment, certain children thrive while others are swept into the spiral of malnutrition and infection that ultimately ends in death or permanent disability. From this observation, Mata concludes that the true cause of poor child health is not lack of food: it is what Mata calls "deficient maternal technology." He defines "good" maternal technology as consisting of the following:

Perhaps "technology" is the key word here, for Mata perceives a woman's inability to promote her children's health as primarily a failure to learn the technical lessons of primary health care. Nodding slightly to some vague social factors that may influence a woman's ability to protect her children, Mata tries to be careful not to lodge moral blame against mothers who fail. On the other hand, Mata stresses, faced with similar circumstances, some women seem to do just fine:

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For Mata, the implications of his insight are clear: food programs to buffer the effects of economic crisis and structural adjustment are not the solution, because lack of food is not the problem. Rather, poor mothers are the problem; thus-improving maternal technology-creating better mothers-must be central to the solution.

Of course, Mata is not wrong when he states that a mother who makes sure the family's food is free from fecal contamination is more likely to have a healthy child than a mother who ignores the risks of contamination. Indeed, Mata and others who support his view probably would concede quite readily that in many cultures, the subordination of women does much to prevent them from learning or implementing the lessons of sanitation. The problem with the view exemplified by the Mata article is that it fails to invest that subordination of women with any importance, programmatically or theoretically.

By failing to pay attention to the elements of women's lives that lie outside the mother-child relationship-by failing to ask the right questions in his comparison of the children who thrive and those who die-he fails to see the multiple, fundamental ways in which economic crisis jolts women's lives and intensifies unequal gender and power dynamics within their households. These are dynamics that all too often lead to violence, marital breakdown, mental illness, and abject despair, and so, to an inability to cope with the

effects of economic crisis.10 At the same time, the intense focus on the mother-child relationship, and the tendency to view women as isolated actors whose sole role in life is the birth and rearing of children, obscures the incredible strength, assertiveness, and resourcefulness that many women have shown in the face of crisis, developing and carrying out strategies that require them to go well beyond conventional gender roles of wife and mother in order to insure their own and their families' survival.¹¹

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Thus, where Mata points to "maternal technology" as the solution to children dying from malnutrition-infection complex, other defensible solutions could be to change (or abandon) structural adjustment programs so that even children in families least able to cope with crisis can survive; and/or to facilitate women's ability to cope by taking measures to increase their autonomy, power, and rights within the families and communities devastated by adjustment pro grams. The public health practitioner trained only in the tech niques of primary health care, and conditioned to think of them as "magic bullets" of unquestioned benefit, all too often will accept uncritically a conclusion such as Mata's. But the feminist or human rights activist attuned to the political implications of medical practice and health policy, will likely ask a different set of questions to understand the dynamics of the household and communities in which children die during economic crisis. Such questions yield a different range of policy conclusions, possibly with primary health care (al beit wrapped in a different implementation package) among them.

Finally, there is another, more general observation to make about the approach exemplified in the Mata article.

Even when the potential influence of social factors such as macroeconomic crisis and structural adjustment programs is acknowledged, public health policymakers and practitioners often resort, almost reflexively, to the same kind of solution: individuals must modify their own behavior. In the case of women, this often means they must become "better" wives, mothers, or homemakers. This is a theme that has been repeated over and over again in current public health discourse and practice, particularly when it comes to health problems prevalent in marginalized populations.

For example, individual behavior change has long been the central theme in HIV/AIDS prevention policy, exhorting all people to "just say no" or to engage only in safer sex practices. Yet, for women who are powerless and vulnerable, caught in marital and sexual relationships over which they have little control, such advice may be worse than useless. Programs that address, or at least recognize, the power imbalances that shape women's lives, are now beginning to re-

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ceive increased attention as the HIV/AIDS pandemic continues to ravage vast parts of the world.¹² But in the United States, at least, this focus on individual behavior as the source of and solution to all social ills is now reaching new rhetorical heights with the Republicans' Contract with America and its cynically-titled centerpiece, "The Personal Responsibility Act" which purports to address the public health issues of "teenage pregnancy and illegitimacy" as well as the budget deficit, by penalizing indigent women who have children.13

I certainly do not mean by this discussion to imply that individual behavior change is irrelevant to improving health and preventing disease. Indeed, I would argue that, as a matter of human rights, individuals must be empowered to make the kinds of decisions about their lives that will enable them to protect their health. But it is also critical to recognize that the decision to focus on individual behavior to the exclusion of other social determinants of ill health is a political choice; it is not an inescapable answer compelled by an indisputable, "scientifically correct" understanding of disease causation. Moreover, the model of behavior modification that typically underlies public health campaigns incorporates a kind of individualism associated with biomedical approaches to, health, that actually does little to empower people to make such changes. As Elizabeth Fee and Nancy Krieger explained it in their article on the history of HIV/AIDS paradigms:

This kind of abstract individualism will surface again in subsequent sections that consider the prevailing conceptions of rights which, like biomedicine, are influenced by liberal theory. But to summarize here: public health tools, and epidemiology in particular, expand our ability to see, to un-

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derstand, indeed to measure, important aspects of the individual's relationship with the world. The fact that epidemiology is grounded in specific contexts, that it is based on statistical measurements that are testable and repeatable, is critically important to practice and effective advocacy. But we must beware of the "false conflation between scientific; objectivity and value-free science."15 Epidemiology-whether the question is which data to gather, how to interpret data we have, or how to craft policies and programs based on the data-will never be value-free, nor do I argue that it should be. But epidemiology and the tools of public health are just that-tools, and methodology. The values that drive their theory and practice cannot be found internally within epidemiology; they must come from outside of it.16

Can health, then, be a value, a "good," in and of itself? My answer is emphatically yes. Only a person blessed with perfect health and blind to the suffering of others could have the arrogance to seriously propose otherwise. Hence, my point here is not to deny that health has biological dimensions or to belittle the importance of physical health as a worthwhile policy goal; rather, my point is to show that even an individual's physical health-not to mention her mental and emotional health-is inextricably tied to the wider conditions of her life. Thus physical health cannot be detached from political and social concerns, posited as an objective state of biological being, and then treated as though the choices we make in pursuit of it are apolitical and compelled by some internal logic that derives solely from health itself.

Yet, the influence of this detached and narrowly bounded view of health is so deep and pervasive in Western biomedical models and the social policies that derive from them, that its impact and operation can be extremely difficult to recognize and even harder to contest.¹⁷ Of course, the inability to perceive the influence of narrow health models or to grasp the fundamental truth that health is socially produced, is a malady that primarily afflicts those of us who are academics, theorists, policy analysts, or health professionals and have been born, bred, and/or trained in the ideology of science and Western biomedicine.¹⁸ By contrast, for the people in every part of the world, north and south, who live the real

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ity of deprivation and discrimination in its harshest forms, the truth of the social production of health and disease is painfully obvious-even if its solutions are not.

Human rights is fundamentally about the struggle to make their voices heard and heeded. In a sense, then, the

collaboration between health and human rights begins here, with the struggle to decide whose view of health will control the policies and programs that address it. Perhaps nowhere is this struggle more contentious, or the collaboration between health and human rights more urgent, than in the area of women's reproductive health and reproductive rights.

The reproductive health and reproductive rights movements grow from the conviction that at the core of human dignity lies the ability to be an effective agent in guiding the course of one's own life. Much of the work by activists and theorists in this field is devoted to understanding what exactly this means across different cultures and political systems, and to finding the social structures and cultural configurations that will promote and support it. That work is underway, but far from complete. The evolving understanding of reproductive health advocated by women's movements and many others in the public health field incorporates a broad, holistic, multi-faceted approach to women's health and health care;¹⁹ as theoretical understandings of reproductive health continue to develop, important initiatives on the ground can and do address specific health concerns in effective ways. There is certainly much to be said from a clinical or programmatic perspective about how such reproductive health initiatives are being designed and implemented (and, indeed, about how they contribute to the advancement of human rights, even if they are not ever perceived as human rights initiatives). But, for explanatory purposes here, it is a perhaps easier to describe what reproductive health and reproductive rights are by showing what they are not, or rather, by showing what these movements have reacted against.

In the health field, they have reacted against population control efforts that treat women as "targets" of contraceptive programs, blatantly manipulating their reproductive

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capacity in order to achieve demographic goals-goals set by dominant elites in pursuit of any number of different political agendas. They have reacted against maternal/child health policies that view the health of women as an instrument to ensure the health of children, and not as an important or valuable matter in its own right. They have reacted against medical institutions that focus on different pieces of women's bodies as discrete biological systems to be prodded, probed, and fixed, rather than seeing women's health as women live it, as part of complex interactive systems tied inextricably to the broader conditions of their lives. And they have reacted against domination by health professionals who present "risk" as if the only thing at stake in deciding whether or not to conceive or give birth is the possibility of physical injury; who obsess about reproduction but ignore sexuality; who preach about "personal responsibility" but fold on questions of power and resources, of vulnerability and discrimination.

This struggle around reproduction goes far beyond the health field, for women's reproduction is viewed as the primary tool for many other political projects as well. Thus, in many societies, a woman's sexuality and reproduction are symbols of her family's honor, to be guarded, watched, and controlled. They are the weapons with which the wars of identity politics are waged; most brutally, they are the scene of "ethnic cleansing." It is these political projects, and many others like them, against which the reproductive health and reproductive rights movements have been forced to define themselves.

Thus, stated in the negative, reproductive health and reproductive rights-indeed, human dignity-are about the right not to be alienated from one's own reproductive and sexual capacity; the right not to have that capacity used as an instrument to serve the interests of other individuals, collectivities, or states without one's consent and without the opportunity to participate in the political processes by which such interests are defined. Stated in the affirmative, the reproductive health and reproductive rights movements are about shifting perspectives, about changing whose point of view, whose values, whose experience, whose choices will control women's reproduction.

Such a shift in perspective will not happen automati

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cally by force of logic, nor will it grow out of a movement that focuses on health alone, or on health as a biological problem to be addressed solely through improved medical techniques. It can only happen when health is understood as a function of the same forces that structure a woman's relationship to the physical and social world around her, and is addressed in policies, programs, and activist movements as such.

Once health is understood in this way, then improving health necessarily means dismantling the systems that have wrested away from women the ability and entitlement to decide the meanings and uses of their bodies and their lives. But it also means building social systems that promote and support women as effective actors who are vested, committed, inseparable and indispensable parts of the families, communities, and states within which they live. This second task, the task of renovating or rebuilding, is not an optional afterthought. It is the essence of the search for human dignity and social justice that is the basic motivation for human rights advocacy. But for that search to be successful, human rights will need to be reclaimed and reshaped to fit a movement that seeks to reflect the experiences and serve the visions of women in diverse cultural and political settings.

If "health" as a political category has a problematic history for women's advocates, so too do "rights." Indeed, feminist theorists have been among the most articulate critics of rights-based legal regimes. While it is surely important for women's advocates and activists to consider these arguments, it is also essential to look beyond the academic debate surrounding rights; to acknowledge the different historically-grounded meanings that "rights" can have to the people who assert them;²⁰ to assess the ways that rights language has been used and manipulated in international discourse; and then to make a strategic decision about the potential utility of health and human rights collaboration in advancing the ultimate goals of their work. This is an ongoing, dynamic process that will not yield one "correct" strategic answer, but rather, different answers at different times and places, all of which can

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effectively contribute to the same, shared political goals. Moreover, it is an exceptionally complex inquiry because it involves not only sensitivity to political dynamics at the international level (e.g., in UN conferences, in bilateral or multilateral governmental relationships, and in the increasingly influential world of international NGOs) but also a sensitivity to the multitude of ways in which international developments interact with very diverse and specific local realities in every part of the world.

Of course, a full treatment of all these issues is again well beyond the scope of these preliminary reflections about health and human rights. In the section that follows, therefore, I attempt only to give a very broad-brush, almost impressionistic, sense of conventional approaches to human rights, women's responses to them, and the political use that various forces have found for both. In doing so, I focus most heavily-even if still only superficially-on a few key aspects of a much bigger set of problems and on one key area of concern (reproductive health and rights) in the hope of stimulating more critical attention to the broader challenges we face as the field of health and human rights develop.

Human rights is conventionally approached as a formal body of law codified in treaties, conventions and covenants. This law was first articulated in its contemporary form in the Universal Declaration of Human Rights (1948) and then further elaborated in legally binding instruments in the International Covenant on Civil and Political Rights (ICCPR) and the International Covenant on Economic, Social, and Cultural Rights (ICESCR) (1966), all of which together form what has sometimes been called the "International Bill of Rights." As an expression of basic values of human dignity and social justice, human rights draws inspiration from and resonates with historical and contemporary legal traditions of many different societies and cultures around the world.²¹ However, as a body of formal law dealing primarily with the relationship between individual citizens and their governments, human rights took its initial doctrinal inspiration from concepts of civil liberties found in Western legal systems

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which, in turn, derive largely from liberal political and economic theory.

That theory, in its classical formulations, embraces an ideology of individualism that has been the lightning rod for much of the criticism of rights. Closely associated with the theory and operation of a capitalist free market economic system, liberal individualism views people abstractly, as self-made, self-contained, separate individuals, isolated from others, pitted against the collective, pursuing their economic self-interest without reliance on the state. In a world so conceived, the purpose of rights is to stake out and protect a sphere of personal freedom; but that freedom is imagined as one built on boundaries: its essence is the right to keep others out, the right to be left alone.

In a legal system premised on such a world view, freedom from others also depends on enforcing the separation between the public and the private: rights are theoretically meant to keep the state out of the private sphere all together, and to operate most meaningfully in the public sphere where they regulate the individual's participation in public life and civil society, and his or her interaction with the law enforcement mechanisms of the state (police and court systems). Thus civil and political rights include such areas as freedom of speech and association, freedom from torture and from cruel, inhuman, or degrading treatment and punishment, the rights to a fair trial, and to life, liberty, and security of person (traditionally interpreted to refer to matters such as genocide, arbitrary arrest and detention, and execution). These civil and political rights, codified in the ICCPR, are often called "negative" rights because they are aimed at limiting the state's ability to encroach on individual freedom, at stopping the state from arbitrary or coercive actions.

By contrast, economic, social, and cultural rights, often called "positive" rights, deal with the state's obligation to create the affirmative conditions that help ensure human well-being. They include such matters as rights to health, education, employment, and housing. By ratifying the ICESCR, a State party "undertakes to take steps to the maximum of its available resources, with a view to achieving progressively the full realization of the rights recognized

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in the present Covenant by all appropriate means, including particularly the adoption of legislative measures. "²² Although these positive rights were certainly central to the initial expansive conception of human rights embodied in the 1948 Universal Declaration, for a variety of reasons-some practical and some political-work in the human rights field has centered almost exclusively on the protection of civil and political rights. Most human rights NGOs have chosen not to address economic, social, and cultural rights, in part because of the near total absence of any methodology to monitor enforcement or define violations of them. Not surprisingly, governments have been equally reluctant to tread on this uncharted territory where implementation implies not just refraining from wrongful action, but also affirmative steps to alter the distribution and spending of public and private resources.

Failure to maintain the interconnection between positive and negative rights is among the primary criticisms that have been levelled against liberal theory and the rights-based legal systems it spawned. At the heart of these criticisms is a fundamental challenge to the notion that people exist as atomistic, disconnected, self-enclosed individuals. A legal system premised on a strict dichotomy between individuals and the collective ignores the extent to which individuals define themselves through, and take meaning from, their relationships with others; it fails to recognize the extent to which "we come into being in a social context that is literally constitutive of us."²³

Seeing the individual primarily in opposition to the collective, liberalism supports the prevailing "negative" view of rights that is designed essentially to keep the state in check and as far out of social and economic life as possible. Within the international human rights scheme, this means emphasizing civil and political rights rather than economic, social, and cultural rights and maintaining a strict distinction between them. As women's human rights advocates have repeatedly pointed out, this distinction results in a formalistic and ultimately hollow view of rights. For example, the right to decide on the number and spacing of children, however important to a women's health in theory, actually means little

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in a woman's life in fact, if there are no health services in place and no contraceptives available.²⁴

More specifically, feminist critics of liberal, rights-based legal systems have demonstrated how conventional interpretations of such laws-including international human rights law-reflect the experience and interests of male elites and fail to accommodate or acknowledge the realities of women's lives.²⁵ Their analyses elucidate the myriad ways in which the separation of the public and the private deflects the reach of rights from the site of women's most pervasive exploitation and deepest vulnerability-the domestic sphere-and obscures the crucial role that women play in the public sphere as we11.26 Though liberal legal systems purport to eschew all interference in the private sphere, particularly the family, feminist critics have shown that it is precisely the operation of such systems of law that structures the most intimate matters of private and family life, rendering the stated ideal of non-interference an incoherent principle and the purported neutrality of law an illusion. ²¹

At the international level, the debate over human rights has other, highly explosive, dimensions that take the discussion well beyond theory, into the harsh political reality within which women's movements operate internationally. Thus, any attempt to find a workable collaboration between health and human rights must also consider the ways that rights language has been manipulated for political ends that may have little to do with the defense or denial of the idea of rights per se.

In international discourse, the problem of rights is often posed as a series of oppositional dichotomies: universalism vs. cultural relativism; the individual vs. the collective; civil and political rights vs. economic, social, and cultural rights; North vs. South or East vs. West. The tensions that lie behind these dichotomies are real ones that need to be addressed carefully by the human rights community. I do not purport to do that here nor do I mean to dismiss such tensions lightly; rather, I wish to make a different point: while the tensions

are real, the choice to pose the issues as either/or dichotomies presumes that the two poles exist only in opposition to

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each other and that the resolution can be only to choose one pole or the other. That is a presumption that serves particular political interests, as becomes clearer when we examine who is using these dichotomies and how they benefit from doing so; and when we see how structuring the problem this way becomes a tactic to be used against women internationally, in an effort to divide and silence us.

Perhaps a start in the bigger task of unpacking and analyzing these dichotomies is to recognize that lying at the crux of the problem is this: foes of women's rights typically characterize any expression by women of their entitlement to guide the course of their own lives as a rejection and denial of any and all ties or responsibility to others or to the collective. In their scenario, there is no such thing as a woman who seeks and gains control over the conditions of her existence yet chooses to live a life built around commitments and connections to others; given the chance-allowed to escape from the domination of patriarchal families and communities-it is presumed that women will abandon those families and communities altogether, in an ghastly display of selfish and hedonistic individualism. This basic conception of the "uncontrolled" woman as a dangerous and destructive force explains, in part, why human rights, with its apparent defense of the individual as against the collective, has become so explosive, particularly when applied to women's reproduction and sexuality, the area in which control over women is guarded most jealously.²⁸

Lest this seem like a melodramatic overstatement of the position of those who oppose women's rights, consider some of the recent pronouncements of leaders of that opposition. For example, in 1992, urging voters to reject the proposed Equal Rights Amendment that would have explicitly prohibited discrimination on the basis of gender, Pat Robertson, leader of the increasingly powerful Christian Coalition in the United States, made this now infamous statement:

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His statements were echoed in more apocalyptic, even if somewhat less picturesque, terms by representatives of the Holy See who, in 1994, led a determined effort to derail the International Conference on Population and Development (ICPD) and to undermine its Programme of Action, a document that explicitly endorsed concepts of reproductive health and reproductive rights and acknowledged their link to human rights. Portraying the Cairo Conference as "basically about a type of libertine, individualistic life style" being imposed by the United States under the sway of "a pervasive feminist influence" that amounted to "cultural imperialism, "³⁰ the Vatican made no bones about how serious it deemed the threat to be:

The Vatican found willing allies for its position in parts of the Muslim world. In statements condemning the conference, officials at Cairo's Al Azhar University, perhaps the most prestigious institution for Islamic scholarship in the world, challenged the Programme of Action reportedly because it "aims to defend sexual relations between members of the same sex or between different sexes outside legal marriage," "undermines parental authority" and "might encourage prostitution."³² Such statements helped touch off a wave of threats from Muslim extremists opposed both to the Conference and, perhaps more significantly, to the Egyptian government. Such opposition was broadcast over loudspeakers during sermons in neighborhood mosques:

Others, speaking to the international press, took their campaign to a more chilling level. As one leader of a militant group based in Cairo is reported to have commented:

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It is thus a slippery slide between and among women's assertion of the right to control their reproductive lives; charges of destructive individualism; the spectre of cultural imperialism; and the evocation of North against South, East against West. Of course, as implied by the discussion of liberalism above, this is not a wholly frivolous position: human rights as classically formulated are Western in origin; and the kind of oppositional relationship between individual and collective that was projected by human rights theory, at least in its conventional formulations, does differ from that lived in most social and cultural arrangements, North and South. Moreover, governments clearly have been selective in the accusations of human rights violations made against one another, often having economic or other ideological interests as the primary consideration. And interactions involving human rights NGOs do sometimes suffer from the same arrogance and myopia that plagues all kinds of cross-cultural exchanges. These are issues in the human rights field that must be taken seriously and handled with honesty and circumspection.

Nevertheless, the structuring of the discussion as a set of oppositional dichotomies and, worse, the conflation of each dichotomous relationship with the others, is disastrous for women in both North and South. When any assertion of individual entitlement by women is automatically characterized as betrayal of the collective, when women are forced to choose between an assertion of themselves and assertion of their national, ethnic, or religious identity, then they have lost the first battle-the battle to set the terms of the debate. When this battle is lost then the result is silence: silence from those in the South who fear the accusation that they are "feminist" or "Western;" silence from those in the North who fear the accusation that they are "cultural imperialists."

The characterization of feminism or women's rebellion against patriarchal structures as simply an alien, Western import denies and attempts to suppress the leading role that women from Asia, Africa, and Latin America have played in defining the terms and setting the direction of women's hu-

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man rights movements and reproductive health and rights movements in their own countries and on the international stage.³⁵ Moreover, it makes invisible the long and rich histories of women's resistance as individuals or as organized movements in those countries and in relation to the diverse cultures within them.³⁶ Finally, this conflation of dichotomies takes the genuine and appropriate circumspection of women in the North who are seriously concerned that their own voices and perspective have dominated some parts of the women's movement, and converts it from useful self-reflection and self-criticism into a paralyzing prescription for political correctness that prevents them from hearing and supporting those women in the South who are taking courageous stands to assert their own visions of human rights. At the same time, it prevents women in the South from building alliances with or supporting the struggles of women in the North by characterizing any attempt to make such alliances or connections, even on an ad hoc basis for specific purposes, as a breach of a different prescription of political correctness, one that views everyone located in the North as undifferentiated agents of imperialism and Western hegemony.

There is obviously much more work to be done to understand the historical and contemporary connections among all these phenomena; and to understand their political use in international discourse about human rights generally and women's human rights and reproductive rights in particular, and the strategic options for resisting them. That work is now urgent, as the politico-religious right will clearly remain a powerful force in international politics for a long time. But it is also important for women's health and rights advocates to remember that these are not the only forces threatened by the idea of women's control over their own reproductive and sexual lives. For many years, resistance to women-centered reproductive health and reproductive rights has also come from much quieter, even if more powerful, quarters. Perhaps the most influential of these are certain of the most conservative segments of the population "establishment" that has set the direction for many of the population policies that national governments have implemented over the last four decades often with the help of, or under pressure from, bilateral and multilateral aid agencies.³⁷

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This part of the population establishment certainly operates from a very different political agenda than the politico religious right. It is therefore instructive to see the extent to which both camps have been driven by similar assumptions, particularly the belief that if women are allowed to escape the control of patriarchal families, communities, and states, they will abandon responsibility for and commitment to the collective. Although this belief rarely surfaces in a strident or even explicit way in the writing or work of population and family planning specialists, its influence can be teased out nevertheless. For example, Susan Cotts Watkins, in an article entitled, "If All We Knew About Women Was What We Read in Demography, What Would We Know?" examines 25 years of this leading academic journal to try to understand the views of women that have driven demographers' work. She shows that demography as a field tends to share the basic view of liberal theory in which women are conceptualized as "separate selves," as "autonomous and impervious to social influence," and ultimately concludes that

This description of demographers' view of women is startlingly contrary to many women's own views of themselves, to their feelings of commitment, their experience of connectedness, and their valuing of relationships (including relationships with their own and others' children, relatives, and friends)-as expressed in narratives, demonstrated in everyday life, and even proven in social science research.³⁹ Yet, in many parts of the world, population and health policies have been routinely built not around women's own experience of the world (as advocated by the reproductive health and reproductive rights movements), but around the assumptions and world view exposed by Watkins. The result is precisely the kinds of programs that evidence a deep distrust of women

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and the decisions it is presumed they would, make if given the chance. Thus, population policies and family planning; programs often tend to exclude women from planning and decision-making processes, and instead impose on them, through methods involving varying degrees of persuasion or coercion, the so-called professional's view of what is good for society, for families, for health and for women-and have the power of the state to back them up.⁴⁰

Given this orientation of the population establishment, it is important to recognize-and question why-they have historically been among the strongest advocates of recognizing "the right to decide freely and responsibly on the number and spacing of children" as a human right. Elsewhere, I have shown that when this was first articulated as a human right, at the 1968 Teheran Conference on Human Rights, a primary motivation was to find a wedge to get contraceptives into the many countries (especially in the South) where they were then illegal or otherwise blocked, in order to control population growth .⁴¹ Although those within the population movement who advocated this human right no doubt genuinely believed that individuals should have the right to use contraceptives and to control their fertility, they perceived-the limits on an individual's right to decide whether to have children very differently from the way women's movements understood the same right when they promoted it.⁴² In short, the primary goal of the population movement was to lower population growth, not to ensure that women themselves had both the right and the ability to control their bodies and lives; thus the "freedom" of the individual to decide was, in the view of the population movement, readily limited by the "responsibility" to make the fertility-limiting decision imposed by government population policies purportedly in furtherance of the greater good. As Susan Watkins put it, commenting on the special issue of Demography on family planning that was published in 1968, the year of the Teheran Conference, "Even when the language seems to empower women by claiming they have the right and the power to choose to control their fertility, they are expected to use this power to control world population growth. "⁴³

Apparently, then, the population control movement be

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lieved that in the human rights framework as conventionally understood, it had found a useful tool for advancing towards its own view of human well-being. Thus, one lesson is clear: human rights, like public health, can be wielded as a tool to promote quite particular political goals that might be substantially different from-even contrary to-the goals of women's advocates. This takes us back to the point made at the very start: while public health and human rights can be powerful tools for generating change, they can also be powerful tools for maintaining hierarchies of power and domination based on gender, race, and class.

If rights, in their conventional interpretations, have failed to recognize or redress women's experience of violation; and if the human rights paradigm, when manipulated either by those who purport to accept it or by those who vehemently reject it, provides fodder to precisely the forces that seek to oppress women, then one might legitimately ask, why bother to use human rights at all? Aren't they more trouble than they are worth, particularly given the notoriously weak enforcement mechanisms in the international system?

My answer begins with the refusal to accept the dichotomies routinely imposed on the discussion. Human rights are strategically valuable because they express, in the broadest terms, basic values-human dignity and social justice-that have historical and contemporary roots in cultures throughout the world. But those values do not dictate a particular lifestyle, or identity, or way of being in the world. Rather, they affirm the fundamental value of human agency: the nature of human beings as effective, social actors.

When read carefully and interpreted in its fullest dimensions, the human rights paradigm enables us to reject as inaccurate and destructive the abstract individualism of liberal theory, the notion of individuals operating in isolation and crude self-interest, seeking to keep others at bay, even while imposing their will on everything, animate and inanimate, around them. At the same time, the human rights paradigm rejects treatment of any person as property, chained to another's or a group's will, to be dominated, controlled, and

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used. Rather, it seeks to create a world in which human dignity adheres in the still distant ideal of choice: the notion; that human beings, constituted through relations with others, can still make choices about their lives, can still have something to say about how to structure and maintain relations with others, be they family, community, or state.

Such an ideal has particular power and importance in our time. In a world increasingly consumed by the most brutal struggles of "identity politics," a politics in which access to power and resources is sought to be determined by group identification, and group identification is prescribed by allegedly immutable characteristics of birth (e.g., race, ethnicity, even religion), then women-whose appearance, behavior and, particularly, sexual conduct, are made to be the symbols of "purity," the quality that is believed to ensure group strength and continuity-are most vulnerable to control and domination.⁴⁴ At the same time, our world is increasingly, and irrevocably, international: in economics, politics, and communications, we are all now bound to each other through complicated webs of dependence, infiltration and, most painfully, inequality and domination. In such a world, human rights affirms the basic entitlement of all people to resources and to the respect and dignity that comes from the ability to consciously, willfully participate in setting the terms of their interactions with the world around them.

No one fools themselves into believing that we are close to such an ideal. No one fools themselves into thinking that its attainment will be easy or that it will come without massive social change, in which some will be required to relinquish power over others. But in the area of health, in which we can see in the most obvious physical terms the results of structures of inequality large and small, we have perhaps the best chance to make a difference, to determine and implement social configurations that can support and promote human well-being. In short, when human rights principles are applied to health, we begin to have the strategic, political basis upon which to mobilize across the divides of nation, culture, class, race, and religion, in support of each other and in pursuit of change.

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To use health and human rights collaboration in this way means rebuilding our understandings of both health and human rights, as well as the vision of human well-being they define and advance, from the ground up. It means taking full account of the very real differences that shape our lives, while giving full respect to our common humanity. It means approaching health and human rights collaboration not as a theoretical puzzle that is worked through in a political vacuum, but rather as a very concrete, contextualized inquiry that begins from the experience of those whose health and human rights are most at stake.

Such work will require the combination of many different approaches at the same time. For example, the women's human rights movement has effectively used the analytically simple, but emotionally and rhetorically powerful, method of personal testimony to force recognition of women's violation, entitlement, and need. This has happened most notably in the area of violence against women, where substantial progress has been made in changing perceptions in both the human rights field ⁴⁵ and the international health field .⁴⁶ To a significant extent, such progress has come as a result of women's demand, quite simply, to be heard. In "tribunals" held in all parts of the world and also in international fora, women's often courageous testimonies of violence inflicted with impunity in both the private and public spheres, demonstrated more powerfully than any amount of academic analysis ever could, that both fields, locked into formalistic, narrow ways of understanding both rights and health, had failed to listen to or acknowledge the impact or importance of such experiences and so had effectively excluded this aspect of women's lives from their purview.

In the area of reproduction and sexuality, enormously valuable work that will ultimately contribute to new understandings of health and human rights, is being done in multidisciplinary, action-oriented field research. This includes, for example, the project being conducted by the International Reproductive Rights Research Action Group (IRRRAG) in seven countries in Africa, Asia, Latin America, and North America, to uncover and document the ways that women

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themselves understand and express their entitlement in matters of reproduction and sexuality;⁴⁷ and the project conducted jointly by Health Action Information Network in the Philippines and the Institute for Development Research in the Netherlands, which through participatory action-research in multiple countries, focuses more specifically on women's experiences of fertility-regulating methods and reproductive health care.⁴⁸

Such reconceptualizing of health and rights beginning with the experiences of women, will also require working at a more theoretical level to transform the way the very words we use in health and human rights work, are interpreted and understood. For example, Rosalind Petchesky, in an essay entitled "Body As Property: A Feminist Re-Vision," attempts to "recuperate the notion of self-propriety"-the idea of "owning" or controlling one's body-by looking "at the variety of local meanings that women in noncapitalist societies, radical democrats, and slaves have given to the idea of owning their bodies, as well as the value that contemporary feminists of color are placing on r-owning their bodies as an aspect of self-definition."⁴⁹ As she puts it, "The `objects of property' may have more to tell us from their vantage point than we can learn from positioning ourselves within the debates of the treatises, the lawbooks, and the political-theory canon."

As with women's approach to human rights more generally, Petchesky's point is not to make women's lives and claims fit within the four corners of the law as it currently is interpreted; rather, her point is to see how the powerful language so basic to that law-in this case, the concept of "property"-can be reshaped to serve the political goals defined by women. The aim is to understand "the language of self/body ownership as a rhetorical strategy for political mobilization and defining identities, not a description of the world." From this perspective, the very notion of "property" is given new meaning:

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The project she envisions has distinctly political importance:

All of these projects that focus intensely on the meanings that women in a wide range of different political, social, and cultural settings express for themselves, are vitally important for the ultimate collaboration between health and human rights. But if we are really to escape the abstract individualism of liberal theory and the biases it has imposed onto biomedicine and conventional rights interpretations-that is, if we are to demand that rights be understood not primarily as a right to build boundaries or to be left alone, but rather as a right to live with dignity in the context of social commitments and relationships-and if we are to demand that health and disease be understood not simply as a function of "free" individual behavioral choices, but rather as a result of lives constrained by social forces such as poverty and discrimination, then we will also need to develop a much more structural critique than can be gleaned from case studies or narratives or anecdotal evidence alone.

This is where public health and its tools hold great potential in strategic collaboration with human rights. As discussed much earlier, public health seeks to understand health and disease not simply as a function of self-contained biological systems of the human body, but also as a function of the wider conditions of a person's life. By looking not just at the health of the individual, but at patterns of health in populations, public health allows us to go beyond isolated anecdotes or incidents and to see social patterns and configurations associated with what is experienced as individual phenomena of death, disability, or disease.

An excellent example of this is a recent article by Susan Greenhalgh and Jiali Li that explicitly attempts to demonstrate how feminists can use the discipline and methodology of demography to reveal patterns and practices not observable through qualitative research.⁵² Working with data from

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a rural area of China, they show how the one-child policy has in practice, been shaped over time through "politics of resistance," then "negotiation," then "submission." By projecting to the population level and documenting the shocking shifts in sex ratios in different age and birth-order cohorts, they enable us to see more than simply a rash of cases of selective abortion or infanticide; rather, they can demonstrate how a policy that began as gender-neutral, ultimately has come to involve massive violence and discrimination against the youngest girls in China and, in the most profound ways, has inflicted terrible damage on the wider society as well. Arguing for the importance of developing a feminist demography, they point out:'

Not only do public health tools (including epidemiology and demography) help us identify and describe health issues as socially constructed human rights issues, they also begin to tell us what to do about them. This is critical in the area of positive rights, where the objective is not just to get the state to stop committing a violation, but rather to get the state to do the right thing to improve the social condition in question. Thus, epidemiologic evidence can show us not only the extent of a health problem and its general association with social conditions, it can also show us in far more refined ways, how particular social conditions interact with biological factors to yield patterns of ill health .⁵⁴ It thus can help us determine where to begin to address state responsibility for dealing with a particular health issue.

But, as the earlier discussion of "deficient maternal technology" in the context of structural adjustment programs demonstrated, this is not a value-free exercise. When health data are analyzed from a feminist perspective (such as demonstrated in the Greenhalgh and Li article), essentially bringing a politicized view of human well-being to the endeavor,

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then the understandings developed from health research can begin to acquire the dimensions necessary to organize and advocate effectively within the framework of human rights law. Rather than simply shouting that something must be done to meet, for example, obligations to ensure a right to health under the ICESCR, we can begin to show that "progressive achievement of rights," requires very specific steps, and then demand that such steps be taken.⁵⁵

Finally, it is important to see that health research can also be used the other way around. Not only can we study particular health phenomena to understand how they are socially produced and can be socially ameliorated; we can also study particular human rights phenomena to understand their implications for health. Mann et al point out that a "coherent vocabulary and framework to characterize dignity and different forms of dignity violations are lacking," and suggest that "a taxonomy and epidemiology of violations of dignity may uncover an enormous field of previously suspected, yet thus far unnamed and therefore undocumented, damage to physical, mental, and social well-being."⁵⁶ While this is certainly true, from the perspective of the affirmative building of health and human rights collaboration, we also need to study advancements in human rights. For example, while some feminist theorists are working from within legal and social science frameworks to "reconceive" the concept of autonomy (in somewhat the same way that Petchesky is doing with "property")," demographers and public health researchers are attempting to understand how changes in women's status/power/autonomy (variously defined) in many different social and cultural settings affect the health and well-being of women, their children and families, and their wider communities. ⁵⁸

It is perhaps this research, as much as anything else, that actually built the momentum for the major shifts in perspective within the population and family planning community that were ultimately incorporated in the Cairo Programme of Action. Many years of careful public health research and writing provided the fuel for advocates of reproductive health and reproductive rights to elaborate and assert a women-centered approach. In the end, the proof that the well-being of all people-men, women, and children-depends on dramatic

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changes in the ability of women to set the course of their lives, became undeniable. To a significant extent, that understanding is now incorporated in the theoretical literature and rhetorical statements that shape the population/family planning/maternal-child health fields-and thus the evolving reproductive health field is beginning, slowly, to convert them, in substantial part, in the reproductive health field. But it will take a human rights movement, one that insists on our common humanity yet respects our diversity, to give those statements real meaning in transforming the relationships of power that shape the health and lives of us all.