March 2007
Rachel Chapman’s life and work intertwine in a beautifully complex and deeply personal way. An African American woman, Chapman was raised by white parents in the first interracial adoption in Massachusetts. As part of a personal journey to discover who she was, she immersed herself in African American studies and literature in college. She studied abroad in Kenya, igniting a lifelong passion to understand the challenges facing
African women—and the surprising similarities in the issues confronting
African American women.
Just in time for Women’s History Month, UWTV spoke with Chapman about her research and the unique perspective she brings as an anthropologist focused on women’s health. She shares her personal experiences of uncovering the barriers to health care for women, from the villages of Mozambique to an urban community in Cleveland, Ohio.
You can also learn more about Chapman’s inspiring work in “Fairness and Factions in Health.”
You earned a bachelor’s in African American studies and a master’s in African studies before pursuing your advanced degrees in anthropology. How did this earlier study help shape the course of your future research?
Beginning with African American studies was a personal search to understand myself and the condition of African American people in the United States. Learning African languages and going to Africa was an extension of that search and understanding. The more I learned, the more I became committed intellectually, professionally, politically to contributing my work, my teaching and my research to answering the question, Why should your ethnicity or your race have such a huge impact on your life chances, on the quality of your life? In that way, the personal is part of my professional trajectory as well; they really come together.
As an anthropologist, what insights do you gain into women’s health issues that may be overlooked by a traditional medical approach?
I think the key word to focus on would be time. Medical professionals may really want to understand, cure, solve and prevent illness, but they often don’t or can’t take enough time to see—within their realm of expertise or practice—the need to look at underlying root causes. I’m obsessed with draining the pond and looking at the apparatus. I used to walk by Drumheller Fountain on campus, and to clean it they drained it and you could see the apparatus that makes the fountain work. That’s a good metaphor for what anthropologists do: we want to drain the water from the pond to see how everything is set up to look as it appears on the surface. I’m passionate about uncovering the deep roots of inequalities. Gender discrimination, for example, is at the surface of society: how things seem to be unequal in terms of women’s health and women’s status. But in fact, if you look at the underlying causes, you need to think about the labor market, you need to think about who has a voice and power over structures that control resources and resource allocation.
For me as an anthropologist, I begin with statistics about health. I want to understand why a black woman in America should, no matter what her class or where she lives, have a higher chance of having a much poorer outcome for her child and herself. That fascinates and saddens me. Even though we’ve changed so many things in this country, African American women’s birth outcomes, for example, are still worse than other groups. To me, that’s just a pulse of a whole other set of inequalities. As an anthropologist, I want to work underneath that statistic, that is, the percentage of poor outcomes such as preterm delivery, underweight babies or infant mortalities. I want to look at the underlying causes, so I find myself talking about domestic violence, living wages, access to health care. It’s the draining of the pond, the holistic approach to anthropology and the excavating strategies of looking deeper and deeper into the how, with the hope that the answers you come up with will inform solutions that are more deeply transformative than putting a Band-Aid on the surface expression of deep-rooted structural violence.
How does society’s distribution of power impact health care, particularly for those on the margins of society?
It’s about what James Ferguson has called the shadows of globalization. When you talk about the margins, I think about how capital and development and investment aren't really comprehensive around the globe. While things tend to be moving faster and farther, and connecting new places and resources in very creative ways, there are whole communities, geographic regions, segments of society that are excluded. In those shadows and gaps left by a globalization process that is jumping over and sidestepping and running, whole communities are left behind, left out, or run right over! The distribution of power obviously impacts health care in those shadows and gaps, where people have the worst health outcomes, the worst health status, the least likelihood of surviving illnesses that may be survivable when people have access to technology and can meet basic needs like food security. It’s trying to figure out how to challenge those dynamic processes that leave such huge gaps, and sometimes that means challenging people’s views that some monolithic globalization process or neoliberal economic policy that puts debt financing over public safety nets is good for everybody. My interest is in looking at health care as a really, really good pulse to measure both the costs and benefits of modern globalizing processes.
Mozambique was actually considered a very bright spot in terms of African investment by multilateral institutions because its economy grew, its gross national product grew; however, on the margins of society people suffered more, and poverty didn't go down for the most poor. A very good index for how communities and societies are doing is looking at maternal and infant mortality rates, and what those rates tell us about the health of those communities. While both mortality rates decreased a bit over the last 20 years in Mozambique, they didn’t decline enough. And in some places, they tend to go back up as people struggle to meet basic needs in the face of growing health challenges, which, for many southeastern and southern African countries, includes HIV. For me, that’s an example of where favoring investment in the industrial sector of Mozambique to facilitate debt repayment while gutting social safety nets actually created more gaps and vulnerabilities for the already vulnerable. It underscores the importance of looking at health challenges or health problems from multiple perspectives.
The uneven distribution of power in society, more than anything, leads to an uneven sense of entitlement. A health care industry like the United States’, which is still geared toward profit rather than people, creates deep issues that need to be addressed regarding who is viewed as being entitled. Distribution of power impacts everything in terms of setting priorities for where resources should go, and then accounting for protections and benefits for people. I think it’s really interesting that even though unequal power has led to a system in which more than 54 million people are uninsured, for example, in this country, Americans overwhelmingly seem to understand that everybody needs health care. How we can bring that widespread belief to bear on our distribution of health resources in this country and, on another level, around the world?
What have you discovered from your research on women’s reproductive health in Mozambique?
If you think about the processes by which institutions such as the World Bank or IMF are attempting to assist developing countries by reorganizing their economies to become more productive, one of the criteria for receiving loans is that countries must significantly cut, erode and eliminate social protections for the most vulnerable people. That includes subsidies for food, education and medicine in Mozambique, where education and health care had been nationalized and free for everyone. This ends up having a very gendered effect in most places around the world, where women are responsible for social reproduction of the family, for food, for nurturing, for education and for household health care. To a great extent, the things that women need to sustain healthy households are taken away, such as a right to health care and education for children. When fees are introduced, women’s health really suffers, because women often have less access to cash than men do.
When I arrived in Mozambique during the cease-fire, the country had some of the highest infant and maternal mortality rates in the world. It was after a 20-year internal war that was very violent and focused on civilians: schools, clinics, teachers, roads, markets. Anything that worked was targeted. A large portion of an already poor population had been forced off their lands and made refugees. Of course it was a pretty terrible health situation. And yet there was this network of health posts because of the work on primary health care and public health care that the country had done in its first years of independence. Way out in the tiny villages, you would find clinics staffed with nurses but few or no clinical supplies—and sometimes no walls or door!
Due to unsafe conditions, the U.S. government didn’t really want American citizens to travel to Mozambique at that time. I gained access to work there through the Ministry of Health and a non-governmental organization based at the University of Washington, now called Health Alliance International. Working through the Ministry of Health, I was looking at Mozambique’s health problems from the perspective of my health-professional colleagues. They were asking, Why don’t women come in for prenatal care if they know the dangers of maternal and infant mortality? To address this question, I spent more than a year developing health councils in the rural villages in one particular province. In every village, people perceived the most important health issues to be the death of infants, women dying in childbirth and infertility. To me that’s kind of a weird trio of things, and I wanted to understand that better. On the other hand, my colleagues in the clinics and hospitals were saying that these women did not know the value of prenatal care, that they chose not to come in because they were lazy, did not understand or did not have time. The women were viewed as either incompetent consumers or as uneducated, at best. Meanwhile, the women really understood that they needed prenatal care, and they really wanted children who survived.
So what I did was to step away from the clinic and my colleagues’ point of view to ask women how they made decisions, follow them through pregnancy and find out why they didn’t seek health care. What I found was that women had very different ideas about what represented the greatest risks to their reproductive health. For the most part, those beliefs emerged from the social and the spiritual world. In communities that had the least, women really fought for the attention of men who could provide resources for the family like cash, water or land. In those climates, people were worried first and foremost about maintaining existing relationships. They didn’t see getting a blood draw as important because no one explained it was a test for syphilis, and due to cuts in the health budget, women no longer received care that they saw as valuable such as free iron supplements. So they actually hid pregnancy as long as they could.
How can this information help with the approach to health care for such women? From a clinic perspective, if women are lazy, uneducated or ignorant, the response would be to create education campaigns promoting prenatal care. But what really needs to be done is to look at how serious poverty creates competition and distrust among people, so that the most vulnerable women are the least likely to use services. All over the world, people were creating safe motherhood projects, but women weren’t coming; they were still falling through the cracks. What I learned was that, by including the social context of people’s decisions, we could actually rethink the organization of health care. All of these discoveries could be used to develop a more compatible, appropriate health care system, as well as push health care policy makers to consider poverty alleviation a health care strategy. This might seem obvious, but it means getting people to rethink the scope of their own work. For example, right now it is quite important in AIDS treatment work that health systems begin to address the need for food security as part and parcel of delivering HIV/AIDS testing and treatment.
How has your study of health issues facing women in Africa contributed to your research and understanding of issues affecting impoverished women in urban America?
I came back to the United States, to Case Western Reserve University in Cleveland, after being in Mozambique for four years. I began to notice the statistics for African American women were much too similar to Mozambique. In east Cleveland, a predominantly black and poor community where Case Western is located, an estimated 10 percent of women received no prenatal care, and another high percentage of women received inadequate prenatal care. And I wanted to understand what was going on; do we really understand why women are getting no prenatal care? Or, like Mozambique, are there other parallel systems? Are people working the system in a way that suits them, because they are afraid of punishment or costs, or have problems with access?
And in fact what you find is that some very similar patterns emerge. The most egregious thing to me is drug testing. While there are some federal guidelines on who should be tested for drugs during prenatal care, often it is only enacted within poor communities of color. This results in really serious outcomes. For example, if the rumor in the community is that you will be tested for drugs and then lose your child, that scares a whole bunch of women who might otherwise seek care. Two populations who really avoided prenatal care were women who were using drugs and those who were in abusive relationships, who wanted to avoid that type of surveillance. You could look at these policies as punishing, with the women really understanding that they needed prenatal care yet avoiding those situations. Even women who did receive some prenatal care would often move from hospital to hospital, so that when they finally gave birth they would have no easily traceable records. Domestic violence appeared within communities in both Mozambique and Cleveland. Although abuse crosses class and race, it was a major issue for poor women in particular and greatly affected their health. In fact, domestic violence often begins during pregnancy and escalates because women have to take their focus away from a partner and concentrate more on their own health and the health of their baby.
Globalization and neoliberal economic policies tend to have the same effect in both communities: the most vulnerable become even more vulnerable because of where jobs go, how jobs pay, how services and benefits disappear. When investments in community infrastructure lessen, in some communities the only exploitable resource ends up being the self and working outside the system, like selling drugs or one’s own body in sex work. This is a growing concern in the age of HIV/AIDS, both here and in Africa. Young women are at the highest risk of infection, not only because of their biology and the pathology of HIV, but because of their vulnerability in the labor hierarchy. Sex work actually becomes a survival strategy in some communities. So the challenge is to work toward not only eradicating poverty, but also developing health and HIV treatment programs that can reach everyone.
What needs to happen to improve women’s health care around the world?
There’s a real push to move toward a gender-aware poverty reduction strategy to improve women’s health. This means moving beyond providing material resources to individual families and communities to also include social collateral. One way is to push back the boundaries of what is permissable for women to do, to help develop new skills and strengthen women’s bargaining power in households, communities and government. It also means supporting community action so that women, families and communities can work to increase their rights, entitlement and protections and benefits on issues like health care, workers’ rights and living wages. And although my studies focus on women’s health care, I have found that poverty issues must be addressed. Women’s intense poverty can keep them from accessing free resources. You need a multiple-pronged approach to improving health care, because health is generated by communities.
What type of research do you hope to carry out in the future?
I think I could spend my whole life trying to understand and improve birth outcomes for women and children. There are still some mysteries about why certain groups of women have premature and low birth-weight babies, which have costs all throughout life for those infants and families that are raising them. I would really like to contribute somehow to understanding that better.
I dream about being able to help facilitate the prevention of maternal-to-child transmission of HIV in Mozambique, of being part of envisioning health care that takes care of the mother and supports families. And that’s a challenge right now, because out of all the HIV-positive demographic groups in Mozambique, the group that disappears the most after testing is pregnant women. They don’t necessarily come back for monitoring, with even fewer returning for treatment during pregnancy. And only a tiny fraction actually receive the one dose of Nevirapine that could prevent the transmission of HIV to babies during birth, which is now almost unheard of in the United States. I will start work on this line of research beginning this summer.
I will also be working with my husband, James Pfeiffer (a professor in UW’s School of Public Health), to look at how churches affect HIV-positive adults’ strategies for finding health care. As autonomous institutions, churches have a lot of influence on people’s daily lives. In the poorest parts of the world, churches are often the places where people go to heal suffering of all kinds. The project will focus on both the United States and Mozambique, examining the parallels in communities that are hard hit with HIV and how churches are filling a gap for people who can’t get health care.
What is the biggest challenge you have faced in the course of your work?
The thing that frustrated me the most during my work in Cleveland was trying to change institutional culture. The corporate way in which hospitals were run meant that they had to make money. For example, they could not get the corporate leadership to make resources available to prevent domestic violence by providing safe havens for women. I learned that doctors and nurses almost dreaded when a patient would disclose domestic abuse because it cost them time and money. You could not change the culture to move resources and people around, and that was very frustrating and ultimately very depressing. It was estimated that up to 60 percent of all trauma at a particular hospital was related to domestic violence, which indicated that we needed to do something different, something based in the community. But as corporate businesses, hospitals didn’t see that as their work. So how do you effect change in that kind of setting?
Despite such huge hurdles, I really want to emphasize the resilience of the women and communities with whom I worked. I saw their incredible generosity, their hope and their amazing ability to make do with next to nothing. It encourages me that I have yet to hear of a community that would not take advantage of real opportunities to improve their lives. All communities insist on the right to envision a better future for their children. So you find that in wars, fertility rates often go up. One explanation is that people, in order to get through the next day, need to believe that something could be better and that another generation will carry on after them. I see a lot of hopefulness in that.
