Mothers betrayed

Every year half a million women die in childbirth, deaths easily prevented. Here Sarah Brown, wife o

Two weeks ago, at Mulago Hospital in Kampala, I sat down next to a mother called Sylvia, resting in bed with her newborn baby after a successful delivery, nearly ready to return to her husband and five older children.

But I also looked through a window into a room containing eight babies, none more than two days old, their little cots covered in malaria nets. The doctors explained to me that in each of these cases, and hundreds more like them in the same hospital each year, the mother had died in childbirth.

The causes of death varied from bleeding and infection to high blood pressure and failure to survive a Caesarean section - all so easily preventable by modern western standards. In Britain, for the same reasons, the death of a mother in childbirth was once a common hazard, a fixture of Victorian life.

Improvements over the past century in antenatal care, health education, and obstetric and gynaecological care have lowered the risks of childbirth. There may be more to do at home, particularly on the health risks to newborn babies. But nowadays, only seven in 100,000 women die when giving birth in Britain.

In sub-Saharan Africa, the conditions and health care for mothers in childbirth are often no better, and sometimes far worse, than we had in Victorian times. In 1987, more than 500,000 women were dying in pregnancy or childbirth every year across the world, 99 per cent of them in developing countries. More than half of all women were delivering their babies with no skilled birth attendant present.

It was because of this terrible toll that 20 years ago, the Global Safe Motherhood Initiative was launched by the World Health Organisation to try to reduce the rates of maternal death. In 2000, the United Nations recognised the shocking rates of maternal death and made their reduction one of the Millennium Development Goals. The fifth MDG committed the wealthiest nations to cut maternal mortality by three-quarters between 1990 and 2015.

Tragically, 20 years after the Global Safe Motherhood Initiative, seven years after the UN Millennium Summit, no progress has been made. If anything, the figures are worse. Of 211 million pregnancies worldwide in 2005, eight million women experienced life-threatening complications during pregnancy or childbirth.

Those with access to skilled care and services tended to survive. But 536,000 died, the vast majority in developing countries, 80 per cent of them totally avoidable. Millions more have continuing health difficulties following obstetric complications, making life after childbirth difficult and painful.

In sub-Saharan Africa, the number of mothers dying in childbirth is around one in 50: up to 100,000 women die each year, and hundreds of thousands of babies and older children are left without a mother.

Visit hospitals in Africa and it is easy to see why. While the Commonwealth Heads of Government Meeting was going on in Uganda, I visited labour wards and delivery rooms at Muhimbili Hospital in Dar es Salaam and Mulago Hospital in Kampala. They are both huge referral hospitals attracting many women from across each city, and they offer the only real emergency obstetric care in their areas.

Mulago alone sees the delivery of 33,000 babies a year, almost one hundred a day. Compare that to the Edinburgh Royal Infirmary where my children were born, which is considered a big UK facility and where just 6,000 babies are delivered each year.

In all my visits, I saw overstretched services at work, committed teams with too few con sultants, nurses and midwives, and insufficient equipment and technical provision. Shortages included basic supplies such as sutures and painkillers, which run out whenever there is an extra-busy day for Caesarean sections or other emergency procedures.

The governments in Tanzania and Uganda are doing their best to make progress.

The Tanzanian president, Jakaya Kikwete, told me this was a personal passion for him, and that his government had pledged to put dispensaries around the country that could also offer antenatal care. In Uganda, I saw the nearly completed refurbishment of a maternity block in the Mulago Hospital grounds. But still the death toll remains stubbornly high.

And what makes the lack of any progress on maternal mortality so depressing and frustrating is that, on other Millennium Development Goals, some progress - albeit slowly - is being made and things are beginning to improve. Millions more children are surviving infancy, receiving vaccinations and going to primary school than were in 2000, their life chances transformed by better health care and education. Even in the uphill struggle against Aids, great progress is being made. In Uganda, HIV infection has fallen from 16 per cent to 5 per cent in the past decade.

Yet we know that for hundreds of thousands of children each year, the improvements we make to their life chances through better edu cation and health care are cancelled out by the loss of their mother. For every mother who dies in childbirth, the life chances of a new baby - as well as its brothers and sisters - can be damaged beyond repair.

Avoidable deaths

It is obviously harder for a child to survive, grow and have a life with choices if there is no mother to provide care, food, protection and education. The statistics bear this out. A study in Indonesia showed that 14 per cent of children aged six to ten who had lost mothers dropped out of school, compared to only 7 per cent of those who had not. Poverty as an adult was far more likely for the former group.

The same study showed that children without mothers were four times more likely to die in their early years - usually of malnutrition or disease - compared to other children.

Internationally, pressure is growing, through the White Ribbon Alliance, a global campaign group dedicated to highlighting the avoidable tragedy of maternal death, supported by the WHO's Making Pregnancy Safer campaign and the Partnership for Maternal, Newborn and Child Health. In the UK, the White Ribbon Alliance is led by the Royal College of Obstetricians and Gynaecologists (RCOG) and I sit on its international advisory group. This has given me the opportunity to meet some of the world's leading experts in this field. It has opened my eyes to the impact of maternal death on the life chances of infants.

The general causes are well understood: high fertility rates lead to greater pressure on resources, inadequate and inaccessible health care makes childbirth inherently risky, and women's low status economically and culturally affects their access to health services and the priority they are given.

There is also broad agreement on the solutions required: greater resources, better education, better access to emergency care, availability of antenatal care to spot problems in advance and quick referrals for mothers with complications.

The RCOG International Office has designed a course teaching young consultants essential obstetric and newborn care. The course is available in Tanzania and Kenya, and I hope it will soon be extended to Uganda. Accompanied by Tony Falconer, RCOG senior vice-president, I met a young doctor in the antenatal clinic at Muhimbili Hospital who had completed the course two months before, and thought his training had already helped him save lives.

The RCOG is taking this work further. In South Africa, it is working to help obstetric experts develop a training package for all local doctors in their third postgraduate year, generally spent in more remote conditions. Momentum is building. I am hopeful that a special session will be devoted to maternal death at next year's international summit in Davos and the Bill and Melinda Gates Foundation is funding projects around the world to raise awareness.

At home, just over a month ago, the International Development Secretary, Douglas Alexander, announced at a conference in London that the UK would commit an extra £100m towards improvements in reproductive health. To meet any of the Millennium Development Goals, we need the will, the means and the momentum. We have seen this in relation to vaccinations, free education and the fight against Aids. Now we must see it on the issue of maternal death, where no significant progress has been made, not just in the past seven years, but in the past two decades.

Each developing country needs a strategic health plan that takes account of local situations, expanding services so that populated central and remote areas alike acquire trained people and resources. The investment needed to improve maternal health is small, but the gains for the poorest children in the world will be huge. We must make 2008 the first year of progress on this neglected Millennium Development Goal.

Sarah Brown sits on the international advisory board of the Royal College of Obstetricians. As founder of the Jennifer Brown Fund, she has been closely involved for the past six years in the area of infant and maternal health

This article first appeared in the 10 December 2007 issue of the New Statesman, How New Labour turned toxic

Picture: Bridgeman Images
Show Hide image

The people is sublime: the long history of populism, from Robespierre to Trump

If liberal democracy is to survive, the tide of populism will have to be turned back. The question is: how?

A spectre of populism is haunting the world’s liberal democracies. Donald Trump’s victory in the US presidential election, the narrow Leave majority in the EU referendum, Theresa May’s decision to call a snap election – breaking the spirit of the Fixed-Term Parliaments Act passed by the government of which she was a member – and Recep Tayyip Erdogan’s victory in the recent Turkish referendum all testify to the strength of the populist tide that is sweeping through the North Atlantic world. The consequences have been calamitous: a shrunken public realm, a demeaned civic culture, threatened minorities, contempt for the rule of law and an increasingly ugly public mood. If liberal democracy is to survive, the tide will have to be turned back. The question is: how?

The first essential is to understand the nature of the beast. This is more difficult than it sounds. Most democratic politicians seek popularity, but populism and popularity are not the same. Today’s populism is the descendant of a long line of ancestors. The first unmistakably populist movement in history appeared well over two centuries ago during the later stages of the French Revolution. It was led by Robespierre (Thomas Carlyle’s “sea-green incorruptible”) and the Jacobins who promised a reign of “virtue”. They were inspired by the cloudy prose of Jean-Jacques Rousseau, who believed that mere individuals should be subject to the general will of the social whole and – if necessary – “forced to be free”. As the revolution gathered pace and foreign armies mustered on France’s frontiers, the Jacobins launched the first organised, state-led and ideologically legitimised Terror in history. Chillingly, Robespierre declared, “The people is sublime, but individuals are weak.” That is the cry of populists through the ages. Appropriately, the Terror ended with Robespierre lying on a plank, screaming with pain before he was executed by guillotine.

The French Revolution – which began with the storming of the Bastille and ended with Napoleon’s ascent to an ersatz imperial throne – has an epic quality about it missing from later chapters in the populist story. Ironically, the second chapter, which opened half a century later, was the work of Louis Bonaparte, nephew of the great Napoleon. In 1848 came a second revolution and a second Republic; Louis Bonaparte was elected president by a huge majority. He tried and failed to amend the constitution to make it possible for him to have a second term; and then seized power in a coup d’état. Soon afterwards he became emperor as Napoleon III. (“Napoleon le petit”, in Victor Hugo’s savage phrase.) The whole story provoked one of Karl Marx’s best aphorisms: “History repeats itself; the first time as tragedy and the second as farce.”

There have been plenty of tragedies since – and plenty of farces, too. Trump’s victory was a tragedy, but farcical elements are already in evidence. Erdogan’s victory was even more tragic than Trump’s, but farce is conspicuously absent. The Leave victory in the referendum was tragic: arguably, the greatest tragedy in the three-century history of Britain’s union state. As with Trump, farce is already in evidence – the agitated comings and goings that have followed Theresa May’s loss of her Commons majority; the inane debate over the nature of the Brexit that Britain should seek; and the preposterous suggestion that, freed of the “Brussels” incubus, Britain will be able to conclude costless trade deals with the state-capitalist dictatorship of China and the “America First” neo-isolationists in Washington, DC. Unlike the French farce of Napoleon III’s Second Empire, however, the British farce now in progress is more likely to provoke tears than laughter.


Picture: André Carrilho

Populism is not a doctrine or a governing philosophy, still less an ideology. It is a disposition, perhaps a mood, a set of attitudes and above all a style. The People’s Party, which played a significant part in American politics in the late 19th century, is a case in point. The farmers whose grievances inspired the People’s Party wanted cheaper credit and transport to carry their products to markets in the eastern states. Hence the party’s two main proposals. One was the nationalisation of the railways, to cheapen transport costs; the other was “free silver” – the use of silver as well as gold as currency, supposedly to cheapen credit. Even then, this was not a particularly radical programme. It was designed to reform capitalism, not to replace it, as the largely Marxist social-democratic parties of Europe were seeking to do.

Rhetoric was a different matter. Mary Elizabeth Lease, a prominent member of the People’s Party, declared that America’s was no longer a government of the people by the people and for the people, but “a government of Wall Street, by Wall Street and for Wall Street”. The common people of America, she added, “are slaves and monopoly is the master”.

The Georgian populist Tom Watson once asked if Thomas Jefferson had dreamed that the party he founded would be “prostituted to the vilest purposes of monopoly” or that it would be led by “red-eyed Jewish millionaires”. The People’s Party’s constitutive Omaha Platform accused the two main parties of proposing “to sacrifice our homes, lives and children on the altar of Mammon; to destroy the multitude in order to secure corruption funds from the millionaires”. The party’s aim was “to restore the government of the Republic to the hands of ‘the plain people’ with which class it originated”. Theodore Roosevelt promised “to walk softly and carry a big stick”. The People’s Party walked noisily and carried a small stick. Jeremy Corbyn would have been at home in it.

Almost without exception, populists promise national regeneration in place of decline, decay and the vacillations and tergiversations of a corrupt establishment and the enervated elites that belong to it. Trump’s call to “make America great again” is an obvious recent case. His attacks on “crooked Hillary”, on the courts that have impeded his proposed ban on Muslim immigrants from capriciously chosen Middle Eastern and African countries, on the “fake news” of journalists seeking to hold his administration to account, and, most of all, his attack on the constitutional checks and balances that have been fundamental to US governance for more than 200 years, are the most alarming examples of populist practice, not just in American history but in the history of most of the North Atlantic world.

There are intriguing parallels between Trump’s regime and Erdogan’s. Indeed, Trump went out of his way to congratulate Erdogan on Turkey’s referendum result in April – which gives him the right to lengthen his term of office to ten years, to strengthen his control over the judiciary and to decide when to impose a state of emergency. Even before the referendum, he had dismissed more than 100,000 public servants, including teachers, prosecutors, judges and army officers; 4,000 were imprisoned. The Kurdish minority was – and is – repressed. True, none of this applies to Trump. But the rhetoric of the thin-skinned, paranoid US president and his equally thin-skinned and paranoid Turkish counterpart comes from the same repertoire. In the Turkish referendum Erdogan declared: “My nation stood upright and undivided.” It might have been Trump clamorously insisting that the crowd at his inauguration was bigger than it was.

***

The best-known modern British populists – Margaret Thatcher, Nigel Farage and David Owen – form a kind of counterpoint. In some ways, all three have harked back to the themes of the 19th-century American populists. Thatcher insisted that she was “a plain, straightforward provincial”, adding that her “Bloomsbury” was Grantham – “Methodism, the grocer’s shop, Rotary and all the serious, sober virtues, cultivated and esteemed in that environment”. Farage declared that the EU referendum was “a victory for ‘the real people’ of Britain” – implying, none too subtly, that the 48 per cent who voted Remain were somehow unreal or, indeed, un-British.

On a holiday job on a building site during the Suez War, Owen experienced a kind of epiphany. Hugh Gaitskell was criticising Anthony Eden, the prime minister, on television and in the House of Commons, but Owen’s workmates were solidly in favour of Eden. That experience, he said, made him suspicious of “the kind of attitude which splits the difference on everything. The rather defeatist, even traitorous attitude reflected in the pre-war Apostles at Cambridge.” (Owen voted for Brexit in 2016.)

Did he really believe that Bertrand Russell, John Maynard Keynes and George Moore were traitorous? Did he not know that they were Apostles? Or was he simply lashing out, Trump-like, at an elite that disdained him – and to which he yearned to belong?

Thatcher’s Grantham, Farage’s real people and David Owen’s workmates came from the same rhetorical stable as the American populists’ Omaha Platform. But the American populists really were plain, in their sense of the word, whereas Thatcher, Farage and Owen could hardly have been less so. Thatcher (at that stage Roberts) left Grantham as soon as she could and never looked back. She went to Somerville College, Oxford, where she was a pupil of the Nobel laureate Dorothy Hodgkin. She married the dashing and wealthy Denis Thatcher and abandoned science to qualify as a barrister before being elected to parliament and eventually becoming prime minister. Farage worked as a metals trader in the City before becoming leader of the UK Independence Party. Owen went to the private Bradfield College before going up to Cambridge to read medicine. Despite his Welsh antecedents, he looks and sounds like a well-brought-up English public school boy. He was elected to parliament in 1966 at the age of 28 and was appointed under-secretary for the navy at 30. He then served briefly as foreign secretary in James Callaghan’s miserable Labour government in the 1970s.

Much the same is true of Marine Le Pen in France. She is a hereditary populist – something that seems self-contradictory. The Front National (FN) she heads was founded by her father, Jean-Marie Le Pen – Holocaust denier, anti-Semite, former street brawler and sometime Poujadist. In the jargon of public relations, she has worked hard to “de-toxify” the FN brand. But the Front is still the Front; it appeals most strongly to the ageing and insecure in the de-industrialised areas of the north-east. Marine Le Pen applauded the Leave victory in Britain’s referendum – she seeks to limit immigration, just as Ukip did in the referendum and as the May government does now.

Above all, the Front National appeals to a mythologised past, symbolised by the figure of Joan of Arc. Joan was a simple, illiterate peasant from an obscure village in north-eastern France, who led the French king’s forces to a decisive victory over the English in the later stages of the Hundred Years War. She was captured by England’s Burgundian allies, and the English burned her at the stake at the age of 19. She was beatified in 1909 and canonised in 1920. For well over a century, she has been a heroine for the Catholic French right, for whom the revolutionary triad of liberté, egalité, fraternité is either vacuous or menacing.

***

The past to which the FN appeals is uniquely French. It is also contentious. A struggle over the ownership of the French past has been a theme of French politics ever since the French Revolution. But other mythologised pasts have figured again and again in populist rhetoric and still do. Mussolini talked of returning to the time of the Roman empire when the Mediterranean was Mare Nostrum. Trump’s “Make America great again” presupposes a past when America was great, and from which present-day Americans have strayed, thanks to Clintonesque crooks and the pedlars of fake news. “Take back control” – the mantra of the Brexiteers in the referendum – presupposes a past in which the British had control; Owen’s bizarre pre-referendum claim that, if Britain left the EU, she would be free to “rediscover the skills of blue water diplomacy” presupposed a time when she practised those skills. Vladimir Putin, another populist of sorts, is patently trying to harness memories of tsarist glory to his chariot wheels. Margaret Thatcher, the “plain, straightforward provincial” woman, sought to revive the “vigorous virtues” of her Grantham childhood and the “Victorian values” that underpinned them.

As well as mythologising the past, populists mythologise the people. Those for whom they claim to speak are undifferentiated, homogeneous and inert. Populists have nothing but contempt for de Tocqueville’s insight that the ever-present threat of majority tyranny can be kept at bay only by a rich array of intermediate institutions, including townships, law courts and a free press, underpinned by the separation of powers.

For populists, the threat of majority tyranny is a phantom, invented by out-of-touch and craven elitists. Law courts that stand in the way of the unmediated popular will are “enemies of the people”, as the Daily Mail put it. There is no need to protect minorities against the tyranny of the majority: minorities are either part of the whole, in which case they don’t need protection, or self-excluded from it, in which case they don’t deserve to be protected.

Apparent differences of interest or value that cut across the body of the people, that divide the collective sovereign against itself, are products of elite manipulation or, in Thatcher’s notorious phrase, of “the enemy within”. For there is a strong paranoid streak in the populist mentality. Against the pure, virtuous people stand corrupt, privileged elites and sinister, conspiratorial subversives. The latter are forever plotting to do down the former.

Like pigs searching for truffles, populists search for subversives. Inevitably, they find what they are looking for. Joe McCarthy was one of the most squalid examples of the populist breed: for years, McCarthyism was a baneful presence in Hollywood, in American universities, newspaper offices and in the public service, ruining lives, restricting free expression and making it harder for the United States to win the trust of its European allies. The barrage of hatred and contempt that the tabloid press unleashed on opponents of Theresa May’s pursuit of a “hard” Brexit is another example. Her astounding claim that a mysterious entity known as “Brussels” was seeking to interfere in the British general election is a third.

As the Princeton political scientist Jan-Werner Müller argues, all of this strikes at the heart of democratic governance. Democracy depends on open debate, on dialogue between the bearers of different values, in which the protagonists learn from each other and from which they emerge as different people. For the Nobel laureate, philosopher and economist Amartya Sen, democracy is, above all, “public reasoning”; and that is impossible without social spaces in which reasoning can take place. Populism is singular; democracy is plural. The great question for non-populists is how to respond to the populist threat.

Two answers are in contention. The first is Theresa May’s. It amounts to appeasement. May’s purported reason for calling a snap general election was that the politicians were divided, whereas the people were united. It is hard to think of a better – or more frightening – summary of the spirit of populism. The second answer is Emmanuel Macron’s. For the moment, at least, he is astonishingly popular in France. More important, his victory over Le Pen has shown that, given intelligence, courage and generosity of spirit, the noxious populist tide can be resisted and, perhaps, turned back. 

David Marquand’s most recent book is “Mammon’s Kingdom”: an Essay on Britain Now” (Allen Lane)

This article first appeared in the 10 December 2007 issue of the New Statesman, How New Labour turned toxic