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feministas, feminismos e frankenstein: um

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feministas, feminismos e frankenstein: um
FEMINISTAS, FEMINISMOS E FRANKENSTEIN: UM EXPERIMENTO
POLÍTICO POUCO ORTODOXO*
Marianna Leite
Resumo: No Brasil, os processos para a redução das mortes maternas foram na maior parte do
tempo mediados por grupos sociais organizados. Todos os movimentos, seja em saúde ou não,
mudaram conforme o cenário político mudou. Este artigo faz uma análise histórica das diferentes
estratégias políticas implementadas pelos movimentos de mulheres destinados a institucionalizar os
princípios do direito de saúde integral das mulheres. Ele discute os resultados colhidos a partir de
entrevistas realizadas com os atores-chave, em especial no que diz respeito à participação feminista
e seu ativismo. Ele usa a analogia de Frankenstein para argumentar que, apesar de seus melhores
esforços, o engajamento feminista com as políticas e o discurso da mortalidade materna foi tardio
possibilitando espaço para a expansão da ideologia conservadora que em si levou a um passo para
trás na saúde e na agenda de direitos humanos. Como resultado, uma teia complicada de programas
e políticas ineficientes existe afirmando lutar pela redução da mortalidade materna quando de fato
reproduzem idéias neo-malthusianas. Isto não só resultou na redução extremamente lenta das
mortes maternas, mas também fomentou um ambiente político em que reivindicações feministas são
excluídas da definição de políticas 'mainstream'.
Palavras-chave: Políticas públicas. Reformas de saúde. Mortalidade materna. Estratégias
feministas.
Introduction
This article compares the processes behind the creation and implementation of formal rules
and programs institutionalising women’s rights to integral health care within the Brazilian public
health system, SUS. It particularly focuses on the processes of the creation of different political
agendas advancing a women’s rights discourses, the actors behind them and the real motivation
triggering each strategy. More specifically, this paper analyses the different political strategies
implemented by the different political networks aimed at institutionalising women’s integral health
care principles and practices in Brazil. By focusing on women’s movements, it discusses the results
gathered from interviews with key stakeholders of the public health1 sector reforms, namely: (i)
policy makers; (ii) health and legal professionals in charge of implementing policies; (iii) women’s
rights advocates; (iv) researchers; and (v) members of international organisations.
*A relevância da obra Frankenstein já foi explorada extensivamente por acadêmicos europeus e norte-americanos
especializados em estudos feministas (Yousef, 2002). Tendo em vista o contexto brasileiro, Alves (2006) a menciona na
análise da transição demográfica e na sua abordagem feminista à biotecnologia
1
There is a large debate dating back to 1975 that adresses the construction (or miscontruction to be more exact) of
public health as an adequate term (Arouca, 1975; Donnangelo, 1975). In Brazil, collective health has been used by
members of the sanitary movement as a more politically charged and appropriate term but public policy rarely is
formulated in those terms.
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Women’s Rights Activism before PAISM
Mesquita (2011) explains that the feminists’ strategies towards integral women’s health care
were and are perceived differently by different policy networks. The different readings of their
engagement with different theories of development and their approach to the issue of maternal
mortality determines that feminist engagement with public policy not always helps fostering a better
environment for the achievement of women’s right to health to its fullest (Mesquita, 2011). As
established by Shiffman and Smith’s (2007) framework, feminists demands for women’s rights
competed with other health-related problems and strategies. Feminist articulation and/or rejection of
particular policy networks sensibly shaped the implementation of women’s rights discourse in
health sector reforms in Brazil and this was particularly visible during periods of transition
(Mesquita, 2011).
Human rights advocacy for family planning was particularly complex under the Brazilian
military government. Up until 1977 the authoritative government had no official program or
position but it in fact implicitly supported population control practices internally while advancing a
progressive family planning discourse externally (Costa, 2004). This position created a space for a
dialogue focused on population policies but at the same time it gave rise to a series of public policy
gaps silent to the right to freedom of family planning (Costa, 2004). This is all because, the time
that preceded the Brazilian democratic transition, health problems could not be discussed separately
from the political system (Mesquita, 2011). At this time, and it is quite a crucial one, marxist
feminists are accused by socialists of fragmenting the democratic movement with parallel demands
involving women’s social roles and essentialised ideals of motherhood (Osis, 1998). But, in 1982,
State Governors are elected in the first democratic elections since the coup; and at this instance
defeat the party of the military giving space for women’s rights advocacy marking a shift away
from the maternal-child paradigm (Osis, 1998).
Women’s Integral Health Care and the Construction of PAISM
Scott (2001) argues that two main issues arise in the context of health policies in Brazil: the
challenge posed by the different demands from unequal social groups and segments; and the
influence that political transitions have over these policies and their implementation. The author
recognises that health policies have changed back and forth depending on the ruling party and the
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politician in charge (Scott, 2001). Along the years politics either focused on maternalistic rhetoric
or women’s right discourse (and perhaps both intertwined instrumentally) (Scott, 2001).
From the 1970s, the term ‘women’s integral health’ - a broad concept that defines women’s
health biologically and socially and takes into account the underlying determinants of illness and
health - was introduced as a form of expansion of citizenship rights and specially aimed at linking
biological and social reproduction in order to encapsulate and challenge gender inequalities and
their differentiated effects on health (Costa, 2004). Corrêa, Alves and Jannuzzi (2006) contend that
women’s integral health was a strategy used by the feminist movements to gather public and
political support towards strategies that tackle inequalities of power. This strategy aimed at
institutionalising the feminist movement for the recognition of human rights such as family
planning and gender equality (Osis, 1998). Although the term women’s integral health embodied
feminist ideals of holistic care integrated across sectors, it could be argued that it was in fact a
proposal created by the federal government based on the principles defended by the movement for
health reform of equity, universality and integrality (comprehensive or holistic care) (Osis, 1998).
The process of creation of the program institutionalising women’s integral health into the
bureaucracy, the Women’s Integral Health Care Program - PAISM, occurred in the late 1970s and
early 1980s which put Brazil at the forefront of the global health and rights debate (Osis, 1998). The
participation of feminists in the sanitary movement for health reform was the embryo for the its
creation (Osis, 1998). The political positioning of the movement for health reform, part of the
insurgence against the authoritative government, allowed for discussions about public policy
focused on women (Costa, 2004). This policy space created by the reformists was used by feminists
as an entry point to mainstream political discourse which eventually influenced the outline of
PAISM (Costa, 2004). Thereafter, PAISM, as well as the strategy used to advance it, would serve as
a reference for future programs on women's health (Mesquita, 2011).
Corrêa, Alves and Jannuzzi (2006) say that PAISM was the first programme to fully address
the issue of women’s integral health as postulated by feminists. Scott (2001) on the other hand
argues that a national programme like PAISM promotes a social perception that privileges
individuals and that is not context-specific. That is, in Scott’s perception (2001), it promotes
individual rights based on generalist assumptions about health and about women as a homogeneous
group. A former bureaucrat at the Ministry of Health argues that the real limitations of PAISM was
that is was conceptualised as a programme and not a public policy and that this limits, to a great
extent, its ability to acknowledge and promote cross-sector action (Interviewee 17). While a
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feminist academic says that PAISM was and is in fact a policy that manages to encapsulate the
entire scope of the concept and that the only challenge lies in its implementation (Interviewee 2).
In spite of the different perceptions of PAISM’s real capacities, it is nonetheless undisputed
that PAISM created more space for the reproductive rights agenda nationally which eventually was
combined with and/or replaced by the use of the women’s integral health terminology (Corrêa,
Alves and Jannuzzi, 2006). Whereas reproductive rights focus on legal entitlements and abstract
definitions that create a framework for activism, women’s integral health promotes integral and
comprehensive care that enables action across sectors (Cook, Dickens and Fathalla, 2003; Costa,
2004). As discussed below, this shaping and re-shaping of feminist discourse affected maternal
health policies.
Women’s Rights Strategies after PAISM and the Policy Process
In 1988, the Federal Constitution was approved creating the unified and decentralised health system
- SUS - and incorporating many of the demands presented at the VIII National Health Conference
by all sectors of society from organised social movements, health professionals to bureaucrats
(Brazil, 1988). The Constitution recognised family planning as a right and condemned forced
contraceptive methods but failed to regulate abortion (Brasil, 1988). According to Alves (2002), this
has to do with the allegiance the socialists had made with the Church during the period of
democratic transition. Politics then was more than ever the art of advancing possible demands and
learning to compromise those that you know that cannot be advanced.
Since its creation, PAISM was only partially implemented and its original political agenda has been
fragmented and depoliticised through the creation of new programs and policies claiming to
advance PAISM, but not quite measuring up to the challenge (Costa, 2009). There is an extremely
rich history of political achievements and draw backs that can be traced from the creation of PAISM
that largely explain the problematic dimensions of the institutionalisation and implementation of
women’s rights to integral health care, as an intrinsic value (Oliveira, 2003; Costa, 2009). This
paper attempts to provide some answers to this enquiry by emphasising the policy process. More
specifically, this analysis only explores key stakeholders perceptions of women’s rights strategies in
terms of policies and projects aimed at maternal mortality reduction. This epistemological position
if based on a large theoretical and empirical work developed around and about the women’s
movement in Latin America (Haas, 2010).
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As Haraway (1998) describes, the international women's movements have constructed ‘women's
experience’ and used this created collective object as one of the most strategic political ‘facts’ of
modern history. Although this political construct served to advance women’s demands it also had
internal political fragmentation as its non-adverted collateral damage (Haraway, 1998). In
Haraway’s (1998) opinion, divisions among women, in particular among feminists, generated a
crisis of political identity whereat the construct of ‘women’s experience’ became elusive serving
most of the time as a justification for the creation and/or maintenance of a system where women
dominate one another.
Haraway also uses an analogy to support her arguments, the cyborg. The cyborg is a concept that
binds imagination and material reality arranging a strategy where possibilities of historical
transformation form new identities that are contradictory, partial and strategic (Haraway, 1998).
Haraway’s cyborg is a son of militarism and patriarchal capitalism (Haraway, 1998). This type of
strategic discourse is embodied in early feminist strategies and in PAISM. This section applies the
arguments present in Haraway’s analogy of the cyborg, but using Frankenstein as the analogy, to
the strategies put in place in Brazil for the reduction of maternal mortality and divides the issue into
three problems: (i) the limited attention given to maternal mortality by feminists; (ii) the political
volatility of the Technical Area for Women's Health; and (iii) the internal divisions created within
the women’s movements.
Limited Attention given to Maternal Mortality by Feminists
As often explained by academics, in spite of a largely feminist participation in the
development of PAISM and its elements, most feminist movements2 decided to emphasise other
components of sexual and reproductive rights like sexual violence and legal abortion instead of
prioritising maternal mortality (Interviewee 29). This is also recognised by many sectors of the
women’s movement, for example, a specialist of maternal-child health and member of the
movement for humanisation of birth (Interviewee 10), argues that this meant the “ghettoisation” of
maternal health as if reproductive rights were only applicable to cases of non-reproduction.
Academics argue that for feminists it was extremely important to oppose everything that
represented the maternal-child paradigm and, at the time, safe motherhood was almost placed
2
There are many different ways of express and represent ideals and this is flagrant in the divisions that exist within
feminists in Brazil. Grupo Curumim of Pernambuco can be cited as an exception to the mainstream feminist approach to
maternal health. Curumim has been working with maternal health since its creation in 1989 and particularly with
humanization of birth from 2000.
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outside of the realm of the sexual and reproductive rights discourse (Interviewee 29). A law
professor and a judge disputes that maternal mortality became a “non-issue”, completely invisible
and depoliticised (Interviewee 21). Note that, in the opinions of academics and those often in charge
of implementing human rights law like judges, this feminist strategy of disengagement represented
the problematics involved balancing political activism (Interviewee 21; 29).
A doctor and abortion activist that was responsible for the implementation of legal abortion
services and that participated in the creation of the Technical Norm for the Humanisation of Legal
Abortion Care by the Ministry of Health, explains that feminist activism in Brazil has an intricate
relationship with each activist’s personal experiences and opportunities (Interviewee 19). The
interviewee says that many women’s rights strategies were built through the exposure to new ideas
and models of political organisation (Interviewee 19). In this sense, not only maternal mortality was
subject to strategic scrutiny so was abortion, for example (Interviewee 19).
A coordinator of a maternal mortality committee, agrees that feminists focused too much on
abortion leaving the problem of unresolved maternal mortality aside (Interviewee 42). However the
interviewee explains that feminists’ engagement with maternal death was also linked to external
forces not necessarily linked to a strategy per se (Interviewee 42). In the opinion of the interviewee,
maternal mortality became a hot issue in the beginning of the 1990s responding to the results
coming from UN conferences but, soon after that, its political momentum faded (Interviewee 42).
International funding directed to NGOs was withdrawn making the issue only a matter of public
policy – an ethereal an unreachable arena for many (Interviewee 42). This obviously ignores the
slow reduction of maternal deaths and that the country’s regional inequalities might mean that the
demographic transition is not reality in poorer regions. This impairs maternal health efforts that are
integrated in a continuum and particularly harm non-governmental organisation that rely of the
availability of external funds for their activism before and/or against the State.
Political Volatility of the Technical Area for Women’s Health
As cited above, Oliveira (2003) argues that the activism surrounding women’s integral
health care is also related to the work developed by the institutionalisation of feminist demands
through the participation of feminists in the State bureaucracy. Maia, Guilhem and Lucchese (2010)
have found that since 2002 there is little articulation between areas of the Ministry of Health
responsible for implementing PAISM - Health Surveillance and Women’s Health. This occurred,
they argue, due to the fact that women’s health issues are still perceived as not part of surveillance
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priorities and in this sense only subject to collaboration through health inspections and thematic
seminars (Maia, Guilhem and Lucchese, 2010).
A former manager at the Technical Area for Women's Health and a current manager at the
Department for the Analysis of the Situation of Health of the Health Surveillance Secretariat notes
that from 1996 the budget for Women’s Health was increased considerably following the
strengthening of the political compromise to implement PAISM (Interviewee 8). The interviewee
notes that this represented the institutionalisation of some of PAISM’s principles through the
decentralisation of the program and the transformation of the normative powers of the Ministry of
Health (Interviewee 8). Despite of its successes, and due to unknown political decisions, the
Technical Areas had its team and budget reduced from 2007/2008 (Interviewee 8).
It is nonetheless important to note that, as defended by academics, the Technical Area for
Women's Health, the Health Surveillance Secretariat along with the Department of Science and
Technology are crucial to continuation of PAISM (Interviewee 2). The articulation among these
areas has afforded particular visibility to the issue of maternal mortality and the importance of the
investigative work developed by maternal mortality committees (Interviewee 2). Feminist activists
also stress the importance of the the Special Secretariats directly linked to the Presidency, for
example the Secretariat on Special Policies on Women and for Human Rights (Interviewee 33). So,
there is some sort of agreement and recognition of the role played by the bureaucracy but at the
same time there is a clear frustration with the lack of articulation within the State apparat.
Women’s Movements Internal Divisions
Perhaps already evident in the above account, another problem that limits women’s rights
activism is the divisions created within the women’s movements and their perceptions related to the
implementation of PAISM. This problem can be analysed from two angles: differences in the
theoretical perception of PAISM; and the segmented political claims arising out of the broader
movement of women’s integral health care. Even though, PAISM is seen as highly positive and
avant-garde, some controversies exist in regards to its terminology and theoretical scope.
Firstly, some feminists headlining the abortion debate challenge PAISM’s terminology as it
is inadequate for SUS’s as a more progressive model of integrated and comprehensive care because
it fragments the delivery of services (Interviewee 19). In the interviewees opinion, the program
presumably deals with a vertical model of care creating thematic areas that are artificially separated
and encapsulated (Interviewee 19). Arguably, if there is no holistic practice at the national level
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then integral care becomes impossible at the local level (Interviewee 19). And also, if policies are
forced upon local levels without dialogue or partnership, little political commitment will be created
at these levels (Interviewee 19). In a sense, this critique indicates that PAISM’s failure to
acknowledge the importance ‘street level bureaucracy’ which to a great extent is responsible for
either ensuring and/or avoiding the implementation of government programs (Lipsky, 1980).
By contrast, a public health academic argues that the initial material and implementation
strategy of PAISM demonstrate that it was conceived as a horizontal policy and not a vertical
program (Interviewee 2). Vertical decentralisation is perceived to only benefit federal entities that
already have a well developed and well funded bureaucracy favouring monopolies (Lobo, 1992).
More importantly, PAISM strategically uses an essentialised notion of women (by re-affirming
socially constructed gender roles to expand the capacity to gather political support) in order to
afford visibility to the issue of women’s integral health care (Interviewee 2; 32). Also, one of the
members of the Feminist Network for Health, elucidates that the terminology was designed to
engage and attract the conservative wings of religious organisations that thought that integral care
would implicate in the provision of abortion services (Interviewee 27). Regardless of the way
accommodates these differing views, it seems clear that the different perceptions on the capacity of
PAISM to deliver on their policy promises were in themselves capable of fragmenting the women’s
movement. This fragmentation weakened women’s rights activism and the gaps in the movement
was explored by the conservative opposition as arguments in favour of alternative policies.
Secondly, a public health specialist and activist of the black women’s movement, says that
because the field of women’s integral health care incorporate so many emerging issues it is
inevitable for there to be divisions within the movement itself (Interviewee 22). The segmented
political claims arising out of the broader movement can be roughly separated into: (i) freedom of
choice and legal abortion advocacy; (ii) activism for the humanisation of birth; and (iii) demands
for the visibility of issue of widespread violence – domestic, sexual and/or institutional. Feminists
are usually positioned politically in terms of the first (although might also work within the other
two) and do so by demanding the full recognition of sexual and reproductive rights and the
availability of services that guarantee their enjoyment.
A professor at a Department of Preventive Medicine (Interviewee 37), emphasises that the
political and strategic divisions within the feminist movement weakens the sanitary reform project
and limits its scope of action. For instance, the separation between claims of violence and
humanisation fail to explore their commonalities (Interviewee 37). Maternal mortality definition
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remains therefore limited to an epidemiological frame of action when in fact it holds a much more
political standpoint (Interviewee 37). In this scenario, issues like the rise of violent acts during
pregnancy by women’s intimate partners are given double invisibility (Interviewee 37).
An activist for the humanisation of birth explains that the movement started as an extremely
politicised criticism of medicalisation of birth and the absence of a medical practice based on
evidences (Interviewee 10). But a paediatrician and local manager at the Municipal Health
Secretariat, elucidates that the movement for humanisation has many actors and many different
approaches that can range from educational activities to complete reorganisation of health services
and articulation (Interviewee 18). The feminist sector of the movement fights against the “perinatal
paradox”, the high medicalisation of birth being associated with higher maternal mortality
(Interviewee 18).
An obstetrician alerts that the dichotomy created between technocratic and humanistic
model of care is a fallacy (Interviewee 20). In the interviewee’s view, excessive technocracy may
increase the risks or the number of maternal mortality but at the same time humanistic care without
proper referral in cases of emergency or complication can be deadly (Interviewee 20). It is claimed
by health professionals and academics that a balance must be struck with the combined use of both
models (Interviewee 28). This is where the problem lies in terms of women’s rights advocacy
(Interviewee 28). In the midst of these discussions feminists are perceived to be polarising the
discussions in terms of the extremes (Interviewee 20; 28). The perception that feminists have
created for themselves of extremists does not help them to create political alliances and alternatives
in the face of a more conservative environment.
According to an activist and birth attendant in São Paulo, the movement for humanisation of
birth is a political construct created by the federal government aimed at gaining wider political
support (Interviewee 12). Many of the activists in the movement for humanisation of birth state that
the main of obstacles face in this area have to do with the profit-seeking capitalist system
(Interviewee 12). Private health plans, doctors and women themselves are some of the actors who
oppose demands for different birth conditions (Interviewee 12). Activists explain that, although
subject to great visibility from the media, there is little dialogue within feminist movements which,
in the interviewee’s opinion, is too focused on working with violence against women and abortion
(Interviewee 12). Feminists on the other hand argue that the movement for humanisation of birth
was co-opted by conservative networks (Interviewee 9). In feminists’ opinion, the movement is part
of a political strategy to exclude extremists and to co-opt moderates (Interviewee 9). This
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demonstrates how diverse the women’s rights activisms maybe across the country, movements and
classes.
Conclusion
We live in a patchwork reality, full of different strategies, feminists and feminisms. The
plethora of demands and political spaces create division within the different feminist movements
which undermined their own epistemological strategies which is crucial for determining possible
articulations. PAISM, as part of feminists initiative within the wider movement for health reform
reform, is a political process that needs to be constantly reshaped and reflected upon. It still difficult
to analyse whether feminists epistemologies will manage to build effective affinities to push for a
more robust implementation of PAISM. It is nonetheless clear that thus far the failure to timely
afford visibility and priority to maternal mortality has allowed for the creation of political spaces
that have been populated and dominated by conservative movements, particularly religious
caucuses. This not only negatively influenced the provision of reproductive health services but also
the delivery of public health under a framework that allows space for practices enclosing the social
determinants of health and illness. In the Brazilian context, the advancement of women’s rights as
intrinsic value is limited by backlashes and setbacks characteristic of not only decentralisation itself
but of the multiple policy spaces it creates.
In sum, it is therefore possible to conclude in light of the Frankenstein analogy that women’s
rights experiences in political activism, particularly feminist activism, were in fact political
experiments. This finding is important in the sense that it calls for a constant and critical
reassessment of the drawbacks and backlashes of these experiments in order to delineate better
ways to move forward. It flags out that women’s rights advancement not only depends on the
success of progressive activism but also of conservative agendas. Obviously, it is safe to say that
other progressive policy networks that are not necessarily aligned with feminists (i.e. affirmative
action and black identity, indigenous’s rights, children’s rights and others) can have positive and/or
negative effects on the achievement of a policy framework for the achievement of women’s rights
as an intrinsic value. But, regardless of other external and competing forces, the data analysed here
suggests that feminists’ strategic distancing from conservative discourses have not always produced
the best policy outcomes.
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Feminists, Feminisms and Frankenstein: An Unorthodox Political Experiment
Abstract: In Brazil, the processes for the reduction of maternal deaths were most of the time
mediated by organised social groups. This article makes a historical analysis of the different
political strategies implemented by the women’s movements aimed at institutionalising women’s
integral health care principles and practices. It discusses the results gathered from interviews
performed with key stakeholders, in particular regarding feminist participation and activism. It uses
the Frankenstein analogy to argue that in spite of their best endeavours, feminists’ late engagement
with maternal mortality discourse and policy making allowed space for the expansion of
conservative ideology which in itself led to a step back in the health and human rights agenda. As a
result, a complicate web of inefficient neo-Malthusian programs and policies now exist claiming to
fight for the reduction of maternal mortality. This not only resulted in the extremely slow reduction
of maternal deaths but also fostered a political environment whereby feminist claims are excluded
the mainstream policy making.
Key words: Public policies. Health sector reforms. Maternal mortality. Feminist strategies.
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Seminário Internacional Fazendo Gênero 10 (Anais Eletrônicos), Florianópolis, 2013. ISSN 2179-510X
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