praise for

From Outrage to Courage

“This book brings together a review of most of the major issues that have engaged
the global women’s movement over the last three decades. Seeking to “make injustice
visible” Anne Firth Murray locates her analysis in the experience of grassroots women
and the issues that affect their lives, including persistent poverty, unequal access
to food, education, health care and money and pervasive violence against women.
Throughout, she looks at the power of women’s activism, going beyond victimhood
to agency to bring about social change.”
—Noeleen Heyzer, Former Executive Director,
United Nations Development Fund for Women (UNIFEM)

“In her passionate and thought-provoking book, Anne Firth Murray documents the
tremendous discrimination and inequities poor women face in the developing world
at every stage of life. These injustices are manifested in high rates of deaths and
illnesses and unequal access to food, health care, education, and employment. Interwoven
throughout the book are inspiring stories of courageous women who are joining forces
to fight for human rights and build the foundation for a brighter future.”
—Elizabeth Maguire, President and CEO of Ipas and former Director of
USAID’s Office of Population

“Anne Firth Murray has done the near impossible in taking a critically important
topic—the health of women in poor countries—which has been dealt with in a
limited, fragmented, piecemeal fashion and given us a passionate, coherent, shock-
ing, truthful, engaging, and utterly persuasive story that should turn your view of
women in poor countries in the right direction. The book will make you sad, it will
make you angry, but it will also give you hope because of the courage and actions of
women in poor countries throughout the world. This book should be read and widely
shared by anyone concerned about justice and our world.”
—Philip Lee, MD, Professor of Social Medicine ( Emeritus ) and Senior Advisor,
Institute for Health Policy Studies, School of Medicine, UCSF
“Anne Firth Murray’s book gives us a moving and insightful perspective on the chal-
lenges and triumphs of women working across the globe to ensure that most basic
of human rights—good health. Her stories of women’s creativity and courage in
mobilizing to ensure equal access to healthcare are inspiring and hopeful. This is a
book about one of the most critical subjects of our time. Read it.”
—Kavita N. Ramdas, President and CEO The Global Fund For Women

“Anne Firth Murray is an inspiration. As Stanford’s foremost authority on international

women’s health and human rights issues, she has inspired a generation of students
to “think big” and take action for a brighter future for women globally. This book
is a must-read for every future leader of our time.”
—Lee Trope, founder and director of the thinkBIG conference on International
Women’s Health and Human Rights

“Anne Firth Murray provides a broad, comprehensive survey of global women’s

health that is grounded in local and personal stories. While detailed accounts of the
devaluing of women at every stage in the life cycle provoke outrage, the efforts to
redress underlying economic, educational, and medical inequalities inspire courage.
This book clearly documents why human rights movements must always address
women’s rights.”
—Estelle B. Freedman, Professor, Stanford University; author, No Turning Back:
The History of Feminism and the Future of Women
 From Outrage
to Courage
The Unjust and Unhealthy Situation of Women in Poorer Countries
and What They Are Doing About It

Anne Firth Murray

new and revised second edition

 Second edition copyright © 2013 by Anne Firth Murray
(The first edition was published in 2008.)
All rights reserved

ISBN-13: 978-0615761169
ISBN-10: 061576116x

Ordering information: This book is available for purchase

through Amazon.com, Amazon Europe, CreateSpace
eStore, CreateSpace Direct, bookstores, and online retailers.

Cover design by Erica Bjerning

Cover photo by Esther B. Hewlett, used by permission
Interior design by Chris Hall/Ampersand

First edition published by Common Courage Press, Monroe, ME

Library of Congress Cataloging-in-Publication Data
for the first edition is available from the publisher by request.

Second edition published by Anne Firth Murray, Menlo Park, CA

www.annefirthmurray.com

Second Edition
To the women who teach courage and resilience.
In the midst of death, life persists;

in the midst of untruth, truth persists;

in the midst of darkness, light persists.

—Gandhi
 Contents

Foreword to the First Edition by Paul Farmer xi

New in this Edition xiii

Prologue: Darkness and Light xv

Critical Issues Faced by Resource-Poor Women xvii

Who is Worth Studying? xix
Turning a Blind Eye to Key Issues xx
The Lens of Mental Health xxi

1. Women’s Health, Poverty, and Rights 1

Women and Poverty 2
Health Defined 5
Women and Human Rights: A Slow Dawning 7
Why Focus on Women? 11
Women’s Courage: Women’s Groups Taking Action 14

2. From the Beginning, A Deadly Preference 25

How Do Girls Go Missing? 28
Demographic Imbalance and its Societal Effects 31
Signs of Changing Times 33
Women’s Courage: Women’s Groups Taking Action 35

3. Childhood: the Hope of Education and

the Persistence of Discrimination 39
Unequal Access to Nutrition and Health Care 40
The Great Hope of Education 41
Education as a Development Strategy 45
 Education as a Human Right 47
Challenges to Girls’ Education 48
A Violent Practice: Female Genital Mutilation 51
Female Genital Mutilation Described 53
Health Consequences 55
Prevention 57
Other Current Challenges: Child Labor
and Trafficking 59
Women’s Courage: Women’s Groups Taking Action 62

4. Adolescence: Change and Vulnerability 75

Adolescence: A Time of Change 76
Early Childbearing and Early Marriage 79
The Female Face of HIV/AIDS 81
Violence and Predation 89
Hopeful Signs 91
Women’s Courage: Women’s Groups Taking Action 93

5. The Maternity Death Road:

Reproductive and Sexual Health 103
Reproductive Choice: Women’s Access to Contraception 107
Safe and Legal Abortion 112
Sexually Transmitted Infections 118
The Evolving Field of Reproductive and Sexual
Health and Rights 119
The Reading of the Names 122
Women’s Courage: Women’s Groups Taking Action 124

6. Violence against Women: Abuse or Terrorism? 133

The Nature and Prevalence of Domestic
Violence against Women 135
Health Effects 138
The Silence Surrounding 140
Triggers and Causes 141
Societal Costs 142
More Family Violence: “Honor” Killing and Dowry Death 143
 Countercurrents against the Tide of Domestic Violence 145
Women’s Courage: Women’s Groups Taking Action 147

7. Women Caught in Conflict and Refugee Situations 161

The Nature of Present-Day War 162
The Devastating Effects of War on Women 164
The Breakout of Conflict 165
Women’s Bodies as Symbols 166
Flight and Forced Migration 168
Sex for Survival 170
Landmines and Disability 171
Unequal Access to Safe Haven 172
Life in a Refugee Camp 173
Reproductive Health Issues 175
Other Health Issues 176
Refugees in Natural Disaster Situations 179
The Aftermath of Conflict 180
Women’s Courage: Women’s Groups Taking Action 184

8. Laboring in a Globalized World 193

Women’s Work: Unrecognized and Undervalued 194
Measuring Work: Not! 195
Informal “Paid” Work 196
Globalization: Boon or Bane for Women? 198
Moving to the City for Pay 204
Sex Trafficking 206
Health and Other Consequences 209
Agents of Trafficking 211
Sex Work by Choice 215
Taking Action 217
Environment, Climate Change, and Women’s Labor 218
Women’s Courage: Women’s Groups Taking Action 221

9. Aging in a Man’s World 233

Demographics and the Feminization of Aging 234
What Does it Mean to be Elderly? 236
 A Lifetime of Work 237
Older Women as Caregivers 239
The Special Case of HIV/AIDS 240
Health Consequences of a Lifetime of Work 242
Social Exclusion and Loss 243
Characteristics of Older Women in Poorer Countries 245
Hopeful Signs 247
Women’s Courage: Women’s Groups Taking Action 249

10. Turning the World Rightside Up 255

The Global Women’s Movement 256
From Development to Human Rights to Paradigm Change 257
The Nature of Feminist Activism 260
Women’s Courage: Women’s Groups Taking Action 263

Endnotes 276

Bibliography 300

Some Useful Resources 333

Gratitudes and a Personal Note 342

Permissions 345

About the Author 346

 Foreword to the First Edition

Anne Firth Murray’s new book is three things at once: a catalogue of

abuses, an analysis of their causes and consequences, and a chronicle of
courage under fire. It is the seamless blending of these strands that make
From Outrage to Courage a tremendous contribution to all those who wish to
understand how poverty and gender inequality conspire to make life miser-
able and short for so many, and, at the same time, a roadmap for those who
wish to do something about it.
Anne Firth Murray is one of America’s best practicing intellectuals. For
a physician, the term “practice” has specific connotations: I first met Anne
when she was creating the Global Fund for Women, which like her latest
book moves from outrage—a necessary but unstable sentiment—to action by
supporting small groups of women taking action in the most pragmatic and
important ways. This book tells the story of these efforts and many others,
taking us across the globe and inspiring all those who wish, who need, to
take heart in the face of unjust suffering.
Murray draws on decades-long experience linking the disparate worlds
that are in fact one world: the world of the affluent (which has generated its
own, often blinkered feminism of glass ceilings) and that of the poor (where
women face very different challenges, from lack of water and food to death in
childbirth or, through sex-selective abortion, death before birth). Through
her scholarship and activism, she has bridged this growing gap in ways that
few others have.
It is also a work of sound scholarship, but free of the jargon that mars
so many studies of this topic. From Outrage to Courage focuses on the social
and health conditions of the world’s poorest women, a topic neglected in the
feminist literature of the affluent world. Anne Firth Murray is not content

xi
xii outrage to courage

to look at only part of our wounded planet: from Latin America to Africa to
the United States, from war zone to refugee camp, from village to slum, she
relates the strength and resilience of unknown but exemplary women strug-
gling to transform their lives and their societies. Anne is one of those rare
writers able to link individual experience—the stories of real women facing
very real problems—with the less visible structural constraints, many of
them rooted in an unjust and globalized economy—against which they must
struggle. Her writing is never the dry language of the academic sociologist,
but the vibrant writing of a scholar in touch with the everyday dilemmas of
women living in, and struggling against, poverty.
In sum, this book is both a call to action and a prescription for “turning
the world rightside up,” to use her felicitous phrase. Without paying atten-
tion to the information, the revelations, and the lessons of Murray’s tour de
force, we are condemned to live in an upside-down world in which poor wom-
en—connected to all of us in the ways so carefully detailed in From Outrage
to Courage—continue to suffer unnecessarily and die untimely deaths. We
are deeply in her debt.

Harvard Medical School and Partners in Health, November 2007

 New to this Edition

Notable to this edition of From Outrage to Courage is a change in the

subtitle of the book; the new subtitle is a much more accurate description
of the contents of the book.

Since the publication of the first edition and during the past two years, we
have updated as many statistics as possible throughout the book, primarily
using United Nations sources. We have located the one hundred descrip-
tions of “women’s groups taking action” at the ends of the chapters and have
provided fifty new examples of such groups throughout the book.

In the Prologue, we have included a brief discussion of mental health, under

the heading “The Lens of Mental Health.” This discussion cannot do justice
to the importance of this topic, but there has been very little reliable research
on mental health issues of resource poor women in resource poor countries.

In the chapter on Women Caught in Conflict and Refugee Situations, we

have added a section under the heading “Refugees in Natural Disaster Situ-
ations,” noting that women, particularly poorer women, die at significantly
higher rates and at younger ages than do men in such disasters as cyclones,
earthquakes, and tsunamis.

In the chapter on Laboring in a Globalized World, we have added a section

under the heading “Environment, Climate Change, and Women’s Labor,”
taking into account the growing recognition by women worldwide that such
issues are relevant to their health and human rights.

Throughout the book, where appropriate, we have updated discussions of

policy issues that may have changed or been dealt with differently since
2007, when the first edition of this book was completed. Small changes have
been made here and there to take into account more recent knowledge and/
or research.