Feminist Bioethics and Global Responsibility: Exploring Health Care Delivery in Kenya

While recognizing the positive steps taken by Western feminist bioethicists to engage, in theory and practice, the gender-based inequity in health care delivery, John Ouko challenges Western feminist bioethics to expand its field of analysis to include a serious engagement with the "unjust policies" of Northern-based global institutions and specifically, their deleterious effects on health care delivery in the global South. The major thrust of his argument is that the structural adjustment programs (SAPs) and conditionalities imposed on nations in the global South by global lending institutions such as the International Monetary Fund (IMF) and the World Bank have forced these nations to reduce or abandon the provision of social services to their citizens and consequently, place the most vulnerable in their societies—specifically, women—at great risk. Alison Jaggar, one of the leading feminist philosophers to raise moral questions about global neoliberalism, calls for urgent action in addressing the devastating effects of neoliberal economic policies on the citizens of the global South, particularly the most vulnerable—women and children: "Engaging in critical assessment of global neoliberalism is one of the most urgent tasks currently facing moral and political philosophy. It is certainly one of the most urgent tasks facing contemporary feminism because global neo-liberalism has been extremely harmful to many, perhaps most, of the world's women" (Jaggar 2002, 123).

Focusing on Kenya, Ouko aims to show how the "unjust policies" of these global lending institutions have adversely affected the economy at the local and national levels and created crises in the health care delivery system, a sector in which women are disproportionately disadvantaged. Borrowing from Alison Jaggar's forceful argument against neoliberal globalization, Ouko documents the role played by the neoliberal economic policies of global lending institutions—from the insistence on free trade and opposition to government regulation to promoting privatization and forcing governments to abandon the provision of social services—in bringing the Kenyan economy to its knees and deepening poverty. Kenya, like most sub-Saharan African countries, was largely successful in providing services such as primary health care and education to its citizens during the first decade following independence. The low interest rates of the 1970s lured Kenya into massive borrowing to finance development projects, but the global debt crisis of the 1980s and the belt-tightening measures imposed by lending institutions forced the Kenyan government to initiate stringent policies, such as cost sharing, that put health care out of the reach of most of its citizens, especially the rural poor and women. Ouko rightly notes that other internally generated factors—property ownership, early marriage, access to education, and harmful traditional practices—increased the marginalization of women and further alienated them from health care services.

The issue of women's health in the global South, as indeed elsewhere, is complex and multi-layered; however, on many levels, Ouko's paper is not very successful in teasing out and engaging the complexity. Its unidirectional approach to understanding the problem undermines a full and more forceful engagement with the complexity and proves inadequate in unearthing the many layers of oppression that combine to create the complex web in which women are caught. I am reminded here of Marilyn Frye's use of the birdcage as a metaphor to illustrate the multiplicity and intersectionality of the different strands of women's systemic oppression and how their interlocking makes escape difficult if not impossible: "Consider the birdcage. . . . It is perfectly obvious that the bird is surrounded by a network of systematically related barriers, no one of which would be the least hindrance to its flight, but which, by their relations to each other, are as confining as the solid walls of a dungeon" (Frye 1983, 5–6). Of course, one can raise moral and ethical questions about the practices and policies of global lending institutions and the numerous ways in which they have wreaked havoc in the global South, but one must also recognize that this is one piece—a big piece I might add—of the puzzle.

While stressing the devastating effects of the lending practices...