Philosophy

Advances in Reproductive Sciences, 2020, 8, 82-95 https://www.scirp.org/journal/arsci ISSN Online: 2330-0752 ISSN Print: 2330-0744 DOI: 10.4236/arsci.2020.81008 Feb. 26, 2020 82 Advances in Reproductive Sciences The Pattern of Women's Reliance on Family Planning Providers in Egypt Hassan H. M. Zaky Department of Psychology, School of Humanities and Social Sciences, and Social Research Center of the American University in Cairo, Cairo, Egypt Abstract Understanding choice of family planning provider is fundamental for policy makers and program managers as they seek ways to both improve the coverage and increase the sustainability and efficiency of family planning services for Egypt to achieve its population objectives. This study focuses first on providing a descriptive profile of the patterns of reliance on sources of family planning services during the early 2000s. Binomial logit models are then estimated to obtain a more in depth understanding of the determinants of the choice of family planning providers in Egypt using the 2000 Egypt Demographic and Health Survey. The study offers insights into a number of aspects of family planning service provision about which there has been less previous investigation. There are marked differences in the extent to which Egyptian women rely on public or private providers for family planning services depending on the type of method they are seeking. Among the more important findings is the consistency women display in the choice of provider among women reporting multiple segments of use. With regard to the determinants of the choice of provider for family planning services, perhaps the most interesting finding is that household wealth was not a significant determinant of the choice of provider. This may reflect that private sources met the demand for family planning services of significant proportions of women in rural areas and among those in the low income groups. Keywords Choice of Family Planning Providers, Women's Reliance, Determinants, Egypt 1. Introduction There is growing appreciation that women who obtain contraceptive services How to cite this paper: Zaky, H.H.M. (2020) The Pattern of Women's Reliance on Family Planning Providers in Egypt. Advances in Reproductive Sciences, 8, 82-95. https://doi.org/10.4236/arsci.2020.81008 Received: January 25, 2020 Accepted: February 23, 2020 Published: February 26, 2020 Copyright © 2020 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access H. H. M. Zaky DOI: 10.4236/arsci.2020.81008 83 Advances in Reproductive Sciences often have other reproductive health care needs, and that women obtaining other reproductive health care may have unmet contraceptive needs and that the needs of both of these groups of women can often be met best by providers who are able to offer a range of services. An inadequate supply of reproductive health preventive and curative services is thought to be an important factor contributing to women's poor health status and high maternal mortality rates in developing countries. Ideally, the availability of reproductive health services should not be a constraint to accessing reproductive health care. Beyond basic availability, other issues relating to supply become important including the factors that affect provider choice in cases where multiple outlets offering the same or similar services co-exist. In looking at provider choice, a common dichotomy is between public and private providers. Where public and private sector outlets offer the same services, they generally differ in terms of price, convenience, etc., leading the user to select an outlet on the basis of income, opportunity costs and personal preferences. In some instances, the public sector may distort the market by extending subsidies to clients willing and be able to pay higher prices for goods and services. Usually research about providers mainly focuses on the supply side such as training of providers [1], knowledge and practices [2], nature of visit [3], provider characteristics [4], the "culture" of service delivery [5], communication with clients [6], and integration of services [7]. On the other side, the demand in many instances is overlooked [8]. In Egypt during the early years of the 21st century, contraceptive and other reproductive health care services were offered by almost 5000 public health care unit, and more than 20,000 private-practice obstetrician-gynecologists, and other sources (such as private clinics, hospital, mosques/churches, NGOs, etc.). Despite of this medical network, which is almost equivalent to that in some developed countries, Egypt contraceptive prevalence rate reached only 56 percent in 2000 with 54 percent depending on modern methods and a total fertility rate of 3.5 live births/woman [9]. Unmet need for contraception reached 11 percent while discontinuation rate was as high as 30 percent within 12 months of starting use. Egypt's population policy at that time was to reach fertility replacement level by the year 2017. This required increasing prevalence, to almost 75 percent, decreasing discontinuation rate and unmet need, plus other reforms on other dimensions, such as the improvement of female education status, which were beyond the scope of this study. Being now in 2020, Egypt was not able to achieve this fertility objective and even changed the whole population policy and its objectives. This article attempts to obtain more detailed insight into the factors that influenced the choice of provider for family planning in Egypt during 2000. An understanding of the historical patterns of provider choice and their determinants will be of use to policy makers and program managers as they seek ways in which to both improve the coverage and increase the sustainability and efficienH. H. M. Zaky DOI: 10.4236/arsci.2020.81008 84 Advances in Reproductive Sciences cy of family planning services for Egypt to achieve its population objectives. While the need for such investigation has been recognized, research relating to the choice of family planning provider in Egypt is limited. Literature addressing aspects of the issue within the Egyptian context includes few efforts [10]. This article has two purposes: to describe historical patterns of reliance on public and private providers among family planning users; and to identify the determinants of the choice of public and private providers in 2000. 2. Data The data on the sources from which women obtained family planning services used in this article was drawn from information collected in Egypt Demographic and Health Survey (EDHS) conducted in the year 2000, which also included a detailed description of the sample. In the 2000 EDHS, family planning source information was collected for all episodes of contraceptive use during the five-year period before the survey. With regard to the current segment of use, information was obtained from all users on the source from which the method was obtained at the beginning of the current segment of use and, for users of methods requiring periodic resuppply (pills, injectables, condoms and vaginal methods), on the source to which user had gone most recently to obtain the method. For episodes other than the current segment, the source was the outlet at which the method was obtained at the beginning of the segment. For purposes of the analysis that followed, the family planning source was generally grouped by sector (public or private). In looking at the sources for methods requiring resupply (e.g., the pill), the source was also looked at from the point of view of the type of provider (clinical and pharmacy/nonclinical). 2.1. Source at Beginning of Current Segment of Use Intrauterine contraceptive Device (IUD) was the most common method in Egypt since it was being used by almost 66 percent of current users. Pill was the second method (almost 18 percent). Table 1 shows the distribution of current users of modern methods by type of source from which the method was obtained at the beginning of the current segment of use. Overall, at the time they began using their method, one in every two of these users went to a public sector source for the method, one-third obtained the method from a private clinic (including private hospital/clinic/doctors, NGO/PVO clinics, and mosque/church clinics), and 11 percent went to pharmacies. The source from which users obtained services at the beginning of the current segment varied markedly by method. Table 1 shows that the majority of IUD insertions occurred at a public sector source (54 percent) while 40 percent of the insertions were performed at private clinics. Four out of five users obtained the injectable at a public sector source at the beginning of the current segment of use, and almost all Norplant insertions took place at public facilities. The comparatively few respondents who reported use of female sterilization were evenly split between those obtaining the H. H. M. Zaky DOI: 10.4236/arsci.2020.81008 85 Advances in Reproductive Sciences method at a public sector provider and those relying on a private provider. At the beginning of the current segment, pill, condom and vaginal method users were more likely to report getting the method at a pharmacy (53 percent, 66 percent, and 46 percent respectively) than from either public or private clinical provider. Figure 1 compares the source at the beginning of the current segment with the source where the last supply of the method was obtained for current users of the pill and condoms. The results indicate that, as expected, many of the users who obtained these methods from a clinical provider switched to a pharmacy for resuppply. 2.2. Differentials in Family Planning Sources by Background Characteristics Table 2 and Table 3 present the distributions of current users by the type of source at the beginning of the segment according to selected demographic and Table 1. Percent distribution of users of modern methods by type of source from which the method was obtained at the beginning of the current segment of use according to the method used, Egypt DHS 2000. Type of source Pill Condom IUD Injectables Nor-plant Female sterilization Vaginal methods All modern methods Public 18.3 16.9 54.0 80.0 95.2 46.5 13.0 49.8 NGO/PVO 0.7 1.7 6.9 2.8 0.0 1.5 0.0 5.1 Private clinical* 27.6 11.8 39.1 14.7 4.8 51.9 40.5 34.1 Pharmacy 53.1 65.9 0.0 2.0 0.0 0.0 46.5 10.9 Other** 0.3 3.7 0.0 0.6 0.0 0.0 0.0 0.2 Total percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of users 1362 140 5112 876 32 217 23 7760 IUD = intrauterine contraceptive device; NGO = non-governmental organization; PVO = private voluntary organization; *Includes private hospital/clinic/doctor and mosques/church clinic; **Includes friends/relatives and other. Figure 1. Type of source at beginning of current segment of use and at last resupply by method. H. H. M. Zaky DOI: 10.4236/arsci.2020.81008 86 Advances in Reproductive Sciences Table 2. Percent distribution of users of the IUD by the type of source at the beginning of the segment according to selected background characteristics, Egypt DHS 2000. Characteristics Source of method at the beginning of segment Total Number of users Public NGO/PVO Private clinical Age 15 24 59.4 6.4 34.2 100.0 738 25 39 54.2 7.2 38.6 100.0 3222 40 49 49.8 6.5 43.6 100.0 1152 Type of place of residence Urban 48.7 6.6 44.7 100.0 2593 Rural 59.4 7.2 33.3 100.0 2518 Region Urban Governorates 48.8 4.3 46.9 100.0 1218 Lower Egypt 54.9 8.0 37.1 100.0 2584 Urban 47.5 10.4 42.0 100.0 755 Rural 58.0 7.0 35.0 100.0 1829 Upper Egypt 57.3 7.2 35.6 100.0 1271 Urban 50.1 6.4 43.4 100.0 593 Rural 63.5 7.8 28.7 100.0 678 Frontier Governorates 44.9 12.1 43.0 100.0 38 Education No Education 62.6 6.1 31.4 100.0 1795 Primary Incomplete 61.8 6.8 31.4 100.0 629 Primary complete, some secondary 57.5 6.3 36.3 100.0 678 Secondary Complete, higher 42.7 8.0 49.4 100.0 2009 Wealth Index Quintiles 1 67.0 4.7 28.3 100.0 655 2 64.8 6.8 28.5 100.0 804 3 60.8 6.7 32.5 100.0 811 4 58.2 7.3 34.5 100.0 983 5 39.5 7.7 52.8 100.0 1858 Working for cash Currently working for cash 46.6 9.6 43.8 100.0 917 Not working for cash 55.6 6.4 38.1 100.0 4195 Partner's Occupation Professional/Technical/Managerial 41.2 7.8 51.0 100.0 1500 Other/Not working 59.2 6.6 34.2 100.0 3612 H. H. M. Zaky DOI: 10.4236/arsci.2020.81008 87 Advances in Reproductive Sciences Continued Number of living children 0 3 51.9 7.4 40.7 100.0 3280 4+ 57.6 6.2 36.1 100.0 1832 Desire for more Wants no more 53.1 6.7 40.1 100.0 3984 Wants more/Unsure 56.8 7.6 35.5 100.0 1128 Total 54.0 6.9 39.1 100.0 5112 socio-economic characteristics for the IUD and pill users-the two most popular methods in Egypt. The tables offer insights into how patterns of reliance on public and private sector providers varied among users of these methods. In the case of pill users, the results also permitted an exploration of the question of how users who consulted a clinical provider when they began using the method differed from users who got the method from a pharmacy without consulting a clinical provider. For IUD users, the tendency to go to public sector sources decreased and reliance on private clinics increased somewhat in importance as the respondent got older. For instance, 59 percent of IUD users 15 24 obtained the method from public sources compared to around 50 percent of those 40 49 years. In the case of the pill, in contrast, age was not strongly related to whether a user went to a clinical source or the pharmacy at the beginning of a segment of use. In addition, among pill users who obtained the method from a clinical source, age differentials in the likelihood of going to a public or private outlet are not marked. Urban-rural residence and place of residence were clearly related to the type of source from which women sought contraceptive services. Rural users were more likely to get the IUD from a public source than urban women. For example, 59 percent of current IUD users in rural areas got the method from a public source compared to 49 percent of urban IUD users (Table 2). Rural users were somewhat more likely than urban users to get the pill from pharmacies without consulting a clinical source. Moreover, urban users who got the pill from a clinical source were much more likely to obtain it at private than at public outlets while rural pill users were more evenly divided between using public and private clinics (Table 3). Looking at the differentials by place of residence, reliance on public sources for the IUD was most common in rural Upper Egypt, followed by rural Lower Egypt. Interestingly, there was somewhat greater variability in the level of reliance of IUD users on NGO/PVO providers by place of residence than existed for other characteristics. Pill users were least likely to get the method from a pharmacy at the beginning of the segment of use in urban Upper Egypt (46 percent) and most likely to get it there in rural Lower Egypt (57 percent). Among urban pill users who did seek services from a clinical provider, private outlets were markedly more popular than public outlets, whether the user lived in the Urban H. H. M. Zaky DOI: 10.4236/arsci.2020.81008 88 Advances in Reproductive Sciences Table 3. Percent distribution of users of the pill by the type of source at the beginning of the segment according to selected background characteristics, Egypt DHS 2000. Characteristics Source of method at the beginning of segment Total Number of users Public NGO/PVO Private clinical Pharmacy Other Age 15 24 19.3 0.2 30.0 50.3 0.2 100.0 171 25 39 18.6 0.6 26.7 53.6 0.5 100.0 855 40 49 16.9 1.2 28.6 53.2 0.0 100.0 336 Type of place of residence Urban 14.5 0.8 33.8 50.6 0.4 100.0 654 Rural 21.7 0.7 21.9 55.5 0.2 100.0 707 Region Urban Governorates 15.2 0.8 33.4 49.5 1.1 100.0 223 Lower Egypt 19.3 0.4 24.0 56.4 0.0 100.0 645 Urban 13.1 0.6 31.1 55.1 0.0 100.0 227 Rural 22.6 0.3 20.1 57.1 0.0 100.0 419 Upper Egypt 18.0 1.0 30.5 50.2 0.4 100.0 469 Urban 15.0 0.6 38.6 45.8 0.0 100.0 188 Rural 20.0 1.3 25.0 53.1 0.6 100.0 281 Frontier Governorates 24.9 2.9 16.0 56.2 0.0 100.0 25 Education No Education 18.4 0.4 21.8 58.7 0.7 100.0 543 Primary Incomplete 19.6 0.5 24.8 55.2 0.0 100.0 191 Primary complete, some secondary 16.9 2.1 32.5 48.5 0.0 100.0 222 Secondary Complete, higher 18.1 0.5 34.0 47.2 0.1 100.0 406 Wealth Index Quintiles 1 26.5 0.0 12.6 60.6 0.3 100.0 177 2 19.1 0.2 16.3 64.0 0.4 100.0 192 3 21.7 1.3 24.1 52.3 0.6 100.0 278 4 19.1 0.8 28.5 51.3 0.4 100.0 301 5 11.4 0.8 41.0 46.7 0.1 100.0 414 Working for cash Currently working for cash 18.3 1.6 28.0 52.1 0.0 100.0 189 Not working for cash 18.3 0.6 27.5 53.3 0.4 100.0 1173 Partner's Occupation Professional./Technical/Managerial 16.9 1.0 37.4 44.8 0.0 100.0 328 Other/Not working 18.7 0.6 24.5 55.8 0.4 100.0 1034 H. H. M. Zaky DOI: 10.4236/arsci.2020.81008 89 Advances in Reproductive Sciences Continued Number of living children 0 3 17.4 0.5 30.8 50.8 0.3 100.0 728 4+ 19.2 0.9 23.9 55.7 0.3 100.0 634 Desire for more Wants no more 17.6 0.9 27.1 54.1 0.3 100.0 1088 Wants more/Unsure 20.7 0.1 29.6 49.1 0.5 100.0 274 Total 18.3 0.7 27.6 53.1 0.3 100.0 1362 Governorates, urban Lower Egypt, or urban Upper Egypt. In contrast, among rural pill users who obtained the method from a clinical provider, the division between private and public outlets is more balanced. A respondent's education and work status, her husband's occupation and the household's position on the wealth index tended to markedly affect the choice of the source among IUD users. Users of these methods who were more educated, working for cash, married to men in professional, technical or managerial occupations, and/or living in a household at the top of the wealth index were less inclined to obtain the method from public sources and more inclined to rely on private clinics than other users. Among pill users, these characteristics also were associated with the type of source, particularly with the likelihood of consulting at a clinic rather than getting the method from a pharmacy. For example, among users at the bottom of the wealth index, 61 percent got the method from pharmacies at the beginning of the current segment of use. In contrast, among users from households at the other end of the household wealth scale, around 41 percent consulted a clinical provider at the beginning of the segment. Regarding injectables which was the third most common family planning method in Egypt (11 percent), the reliance on public providers was very clear regardless of background characteristics of users. However, reliance on private providers increased with age, education, and wealth of users, and among urban residents (table not shown). Finally, despite the close association between the user's socio-economic level and the likelihood of reliance on a private clinical provider for contraceptive services, the findings also indicated that many users belonging to relatively wealthy households obtained services from public providers. For example, 40 percent of the current IUD users living in households ranked at the top of the household wealth index obtained the method from a public provider. 2.3. Consistency in Choice of Sources The 2000 EDHS collected information on the source from which a user obtained the method for all segments of use of family planning methods during the five-year period before the survey. These data were used to answer questions about whether family planning users tended to remain "loyal" to a particular H. H. M. Zaky DOI: 10.4236/arsci.2020.81008 90 Advances in Reproductive Sciences type of source in accessing services or whether they "switched" public and private sources for services. Since injectables were for the most part only obtained from public sources, the analysis of patterns of consistency was limited to IUD and pill users who reported two or segments of use of the method during the five-year period before the survey. Regarding consistency of type of provider among IUD users, Table 4 shows the percent distribution of women reporting multiple segments of IUD use during the five-year period prior to the survey by type of source from which method was obtained during the segments of use according to the number of segments of use. The results clearly suggest there was a high degree of consistency in the type of provider. Four in five of the women who reported multiple segments of IUD use relied on the same type of provider across all of the segments of use. Forty-five percent were consistent in the choice of a public provider, 31 percent always went to private source, while 5 percent consistently got the IUD from a NGO/PVO clinic. Table 5 indicates that, like IUD users, pill users tended to be consistent in Table 4. Percent distribution of IUD users reporting multiple segments of use during the five-year period prior to the survey by the type of source from which method was obtained during the segments of use according to the number of segments of use, Egypt DHS 2000. Source Two Three Total reporting multiple segments of IUD use Always same type 81.3 69.6 81.0 Public 45.0 33.4 44.7 NGO/PVO 5.3 5.3 5.3 Private 31.0 30.9 31.0 Different types of sources 18.7 30.4 19.0 Total Percent 100.0 100.0 100.0 Number of women 776 20 797 IUD = intrauterine contraceptive device; NGO = non-governmental organization; PVO = private voluntary organization; Note: Private includes private doctor/clinic and mosque/church clinic. Table 5. Percent distribution of pill users reporting multiple segments of use during the five-year period by consistency in the kind of provider (clinical versus pharmacy/other) from which the pill was obtained according to the number of segments of use, Egypt DHS 2000. Source Two Three Four/more Total reporting multiple segments of pill use Always same type 79.3 80.2 94.6 80.3 Always clinical source 25.3 20.5 27.8 24.7 Always pharmacy 54.0 59.7 66.8 55.6 Clinical and pharmacy 20.4 19.8 5.4 19.7 Total Percent 100.0 100.0 100.0 100.0 Number of users 274 58 18 350 H. H. M. Zaky DOI: 10.4236/arsci.2020.81008 91 Advances in Reproductive Sciences the choice of provider across multiple segments of use. Only around 20 percent of pill users switched between a clinical source and the pharmacy. More than half pill users consistently got their method from the pharmacy, and one woman in every four obtained it from clinical sources. Among those pill users who consulted clinical sources, this group of women also tended to be consistent in the choice of the type of clinical provider. 91 percent were consistent while only 9 percent used different types of providers. Among consistent users, 80 percent always used private sources while 11 percent relied on public sources. 3. Effect of Women's Characteristics on Choice of Family Planning Providers Studies of the demand for health care examined the effect of various provider characteristics on consumers' choice of provider for general medical care. In the family planning literature, estimation of the effects of quality characteristics of providers on choice of provider has been attempted [4]. The focus has always been the provider's characteristics. The users' or consumers' perspective is usually treated as a side issue. This article attempts here to further examine the determinants of the type of provider on which Egyptian women relied. The basic model used for exploring this question is a standard utility maximizing model which assumes that choice of provider is a function of the age of individual client, her educational status, work status, husband's occupation, number of living children, region of residence, household wealth, and type of method. The binomial logit model is used and the odds ratios are estimated. Several model specifications are tested. Model 1 includes all users of the pill, IUD, and injectables who obtained their method from either a public sector provider or from a private doctor/clinic; users getting the method from other types of sources are excluded from the analysis. Model 2 is limited to users who also had a birth in the five-year period before the survey. In addition to the basic socio-demographic variables, a variable on the use of antenatal care services is introduced into this model. Model 3, which is limited to users who had a birth and obtained antenatal care services, includes a variable on the type of provider from which the antenatal care for the last birth was obtained. The results of Model 1 indicate that the older the woman is the higher her odds to choose private family planning providers. Older women (40 49) have double the odds to go to private sources compared to younger women (15 24). IUD and Injectables users had at least thirteen times the odds for choosing a public source than pill users have. Increased education was associated with reliance on private provider. Somewhat surprisingly, employed women were more likely to go to public providers. Probably this result was due to that employed women mainly work in the public sector which was linked to a public health care and health insurance systems. Women married to men working in managerial/technical/professional jobs were more likely to get their contraceptive meH. H. M. Zaky DOI: 10.4236/arsci.2020.81008 92 Advances in Reproductive Sciences thods from private providers than others. Rural Upper Egypt residents tended to go to public sector providers. Surprisingly, household wealth was not significantly associated with the type of provider from which the user obtained her method. The addition of use of antenatal care in the second model provides some additional insight into the patterns of provider choice. Users who had given birth in the five-year period and received antenatal care were significantly more likely to have obtained a method from a private provider. It is worth noting that age was no longer important in determining type of provider which may be related to the fact that older users who had a recent child were a select subset of all users in those age groups. Confining the analysis to those who received antenatal care (Model 3), the consistency of provider choice was clear; women going to public providers for antenatal care tended to go to public providers for their family planning method, almost four times the odd of going to a private provider. The study considers two more subsets of users, namely IUD and pill users. For IUD users, the results paralleled the findings for all users in Table 6. Older and more educated IUD users and those married to men in managerial/technical/ professional occupations were more likely to obtain the method from private providers. Employed women were more likely to go to public providers. Rural Upper Egypt users were more likely to rely on public sources. Wealth apparently had no bearing on women's choice of one type of provider over the other. With respect to the pill, the tested model considered the determinants of the likelihood of getting the method from the pharmacy at the pharmacy versus a clinical provider. None of the variables were significantly related to type of provider with the exception of residence in rural Lower Egypt where users had lower odds to getting the pill from pharmacy. It was hypothesized that the lack of fit for other determinants might be due to the very high prevalence use of pharmacy since 84 percent of users obtain the pill at a pharmacy. However, when a model was run in which the group of pill users was limited to those who consulted a clinical source at the beginning of the segment of use, none the socioeconomic determinants of interest were related to the type of clinical provider (not shown in table). 4. Concluding Remarks and Policy Implications A number of conclusions can be drawn from this examination of family planning providers in the early 2000s. First of all, the study confirmed the fact that there were marked differences in the extent to which Egyptian women relied on public or private providers for family planning services depending on the type of method they were seeking. This is perhaps most clearly illustrated in the well-known association between the type of method used and the source from which women seek contraceptive services. Pharmacies supplied the vast majority of pill users, public facilities served the vast majority of injectable users while IUD users were more equally divided between those seeking services from public H. H. M. Zaky DOI: 10.4236/arsci.2020.81008 93 Advances in Reproductive Sciences Table 6. Odds ratios of binomial logit models for choice of type of family planning provider. Explanatory Variables Dependent Variable: Type of family planning provider (Private = 0; Public = 1) Model 1 Model 2 Model 3 Age 15 24 Rc Rc Rc 25 39 0.854* 0.954 0.915 40 49 0.591*** 0.764 0.573 Number of living children 0 3 children Rc Rc Rc 4 or more children 1.108 0.970 1.047 Type of contraceptive method Pill Rc Rc Rc IUD 13.475*** 13.417*** 10.493*** Injectables 43.118*** 42.857*** 31.019*** Region Urban Governorates Rc Rc Rc Urban Lower Egypt 1.017 1.096 1.158* Rural Lower Egypt 1.099 1.257* 1.272 Urban Upper Egypt 1.011 1.101 1.059 Upper Egypt Rural 1.297** 1.453*** 1.367* Frontier Governorates 1.144 1.169 0.954 Education No education Rc Rc Rc Primary complete 1.061 1.267** 1.259 Primary complete/some secondary 0.640*** 0.757*** 0.758** Secondary/higher 0.268*** 0.360*** 0.415*** Women's work status Not working for cash Rc Rc Rc Working for cash 1.325*** 1.332*** 1.356** Husband's occupation Other/Not working Rc Rc Rc Professional/technical/managerial 0.695*** 0.715*** 0.698*** Household wealth index score 1 Rc Rc Rc 2 4 1.001 1.059 1.136 5 0.847 0.956 1.020 H. H. M. Zaky DOI: 10.4236/arsci.2020.81008 94 Advances in Reproductive Sciences Continued Antenatal care No Rc Rc Rc Yes 0.691*** Antenatal care provider Private Rc Rc Rc Public 4.374*** Constant 0.176*** 0.166*** 0.098*** N (number of women) 6647 4063 2336 Df 17 18 18 -2 Log Likelihood 7340.010 4401.632 2544.701 Rc = reference category for the variable. ***p < 0.01; **0.01 < p < 0.05; *0.05 < p < 0.10. sector providers and those obtaining the method from private providers. The study offered insights into a number of other aspects of family planning service provision about which there had been less previous investigation. Among the more important findings was the consistency women displayed in the choice of provider. The majority of women reported multiple segments of use of the same family planning in the five-year period before the survey reported obtaining the method from the same type of source at each segment of use. With regard to the determinants of the choice of provider for family planning services, perhaps the most interesting finding was that household wealth was not a significant determinant of the choice of provider. This may reflect that private sources met the demand for family planning services of significant proportions of women in rural areas and among those in the low income groups. Also, significant numbers among those in the high income groups were almost paying nothing to get their methods. This finding had significant policy implications since it suggested that public subsidies were not reaching those in need the most. More in-depth analysis was needed to identify causes of such distortions in the service delivery system and ways to correct it as well as using the most updated EDHS surveys to analyze trends and changes in consumer's behavior as Egypt scales up its new health insurance system. Conflicts of Interest The author declares no conflicts of interest regarding the publication of this paper. References [1] Speizer, I., et al. (2000) Do Service Providers in Tanzania Unnecessarily Restrict Clients' Access to Contraceptive Methods? International Family Planning Perspectives, 26, 13-20 + 42. https://doi.org/10.2307/2648285 [2] Stanback, J. and Twum-Baah, K. (2001) Why Do Family Planning Providers Restrict Access to Services? An Examination in Ghana. International Family Planning PersH. H. M. Zaky DOI: 10.4236/arsci.2020.81008 95 Advances in Reproductive Sciences pectives, 27, 37-41. https://doi.org/10.2307/2673804 [3] Landry, D. and Forrest, J. (1996) Private Physicians' Provision of Contraceptive Services. Family Planning Perspectives, 28, 203-209. https://doi.org/10.2307/2135839 [4] Akin, J. and Rous, J. (1997) Effect of Provider Characteristics on Choice of Contraceptive Behavior: A Two-Equation Full-Information Maximum-Likelihood Estimation. Demography, 34, 513-523. https://doi.org/10.2307/3038306 [5] Schuler, S., Bates, L. and Islam, M. (2001) The Persistence of a Service Delivery "Culture": Findings from a Qualitative Study in Bangladesh. International Family Planning Perspectives, 27, 194-200. https://doi.org/10.2307/2673855 [6] Kim, Y., et al. (2000) Self-Assessment and Peer Review: Improving Indonesian Service Providers' Communication with Clients. International Family Planning Perspectives, 26, 4-12. https://doi.org/10.2307/2648283 [7] Mayhew, S., et al. (2000) Implementing the Integration of Component Services for Reproductive Health. Studies in Family Planning, 31, 151-162. https://doi.org/10.1111/j.1728-4465.2000.00151.x [8] Frost, J. (2001) Public or Private Providers? U.S. Women's Use of Reproductive Health Services. Family Planning Perspectives, 33, 4-12. https://doi.org/10.2307/2673736 [9] El-Zanaty, F. and Way, A. (2001) Egypt Demographic and Health Survey 2000. Calverton, Maryland, USA; Ministry of Health and Population, Egypt; National Population Council and ORC, Macro. [10] Heilman, E. and Martinkowsky, M. (1993) Trends in the Costs of the Family Planning Program in Egypt, Cairo, Egypt: National Population Council, Special Report Prepared under the OPTIONS II Project, 1993.


Solidarity Care: How to Take Care of Each Other in Times of Struggle

Philosophy

Being aware of social injustices can cause existential and mental pain; comes with a burden; and may impede a flourishing
          life. However, I shall argue that this is not a reason to despair or to choose to be willfully ignorant. Rather, itâs a reason to
          conclude that being conscious is not enough. Rather, during times of oppression, resisters must also prioritize well-being.
          One way to do this is by extending what I refer to as solidarity care. I begin by providing an account of solidarity care. I then
          offer pragmatic ways in which one can extend solidarity care to others. I conclude by responding to two possible worries

Volume 3, Number 1 Spring 2020 DOI: 10.25335/PPJ.3.1-4 Being aware of social injustices can cause existential and mental pain; comes with a burden; and may impede a flourishing life. However, I shall argue that this is not a reason to despair or to choose to be willfully ignorant. Rather, it's a reason to conclude that being conscious is not enough. Rather, during times of oppression, resisters must also prioritize well-being. One way to do this is by extending what I refer to as solidarity care. I begin by providing an account of solidarity care. I then offer pragmatic ways in which one can extend solidarity care to others. I conclude by responding to two possible worries. Abstract Solidarity Care How to Take Care of Each Other in Times of Struggle Myisha Cherry 1. The Problem of Awareness The epistemic state known colloquially in the United States as "Being Woke" has become a pop-culture phenomenon. A pop song commanding listeners in a falsetto to "stay woke" is the first tune we hear in the 2017 hit movie Get Out, a film that reveals in horrific and thought-provoking ways the scary reality that some white liberals may not be as woke as many assume. Although a slang term indeed, "woke" proved its pop-culture dominance when it appeared in the dictionary in 2017. Merriam-Webster now defines it as being "aware of and actively attentive to important facts and issues (especially issues of racial and social justice)." Writing about the concept, blogger Raven Cras claims: The phenomenon of being woke is a cultural push to challenge problematic norms, systemic injustices and the overall status quo through complete awareness. Being woke refers to a person being aware of the theoretical ins and outs of the world they inhabit. Becoming woke, or staying woke, is the acknowledgment that everything we've been taught is a lie . . .. Woke(ness) provides us with a basic understanding of the why and how come aspects of societies' social and systemic functions. The phrase itself is an encouragement for people to wake up and question dogmatic social norms. It requires an active process of deprogramming social conditionings, focusing on consistent efforts to challenge the universal infractions we are all subjected to. However, in order for one to stay woke, one must first, be woke.1 The term is not recent but is said to go back to a 1962 New York Times article "If You're Woke You Dig It," by William Melvin Kelley.2 Some might even recall similar reiterations of the term expressed in late '80s and early '90s rap music by artists who would eventually become known as "conscious" rappers because they were aware of how social structures function, and they challenged––through rhyme––such structures. Essayist and novelist James Baldwin uses this latter term in The Fire Next Time to describe aware citizens––referring to them as "relatively conscious whites and relatively conscious blacks."3 Consciousness, like wokeness, referred to a state of being aware of injustices, sharing that knowledge and even decrying manifestations of injustice. If ignorance is bliss, as some claim, one might wonder about the advantage of having such 1. Raven Cras, "What Does It Mean to be Woke," Blavity News, September 26, 2015, blavity.com/ what-does-it-mean-to-be-woke/what-does-itmean-to-be-woke?category1=opinion. 2. Some even claim that it goes back to the 1940s. 3. James Baldwin, The Fire Next Time (New York: Vintage International, 1993), 105. Without community there is no liberation, only the most vulnerable and temporary armistice between an individual and her oppression. -Audre Lorde (2007) Cherry PPJ 3.1 (2020) 2 an awareness. More specifically, given the seduction and comfort that comes from being willfully ignorant of suffering and injustice (as well as their sources), why then would anyone choose to be woke, conscious, or aware. It is, I claim, because there are benefits. The first is an epistemic benefit. By being woke, one is able to see and perhaps understand the world for what it is: a world that is filled with wonder and beauty but also a world, particularly this American part of the world, filled with inequality, oppression, social exploitation, and social exclusion. This epistemic benefit is the red pill from The Matrix (1999). While the metaphorical blue pill may give you security, it will also make you ignorant. On the other hand, while the red pill may give you unpleasant knowledge and expose you to cruel truths, it still gives you knowledge and truth nonetheless. This truth is valuable within itself.4 There is also a utility benefit to being woke: for one can only challenge systemic injustices after she is first able to see that injustices exist. As legal scholar Kimberlé Crenshaw eloquently puts it, "When you can't see a problem, you can't solve it."5 Although there are benefits to being woke, I have a worry. I wonder if the public's obsession with being woke, and the discourse around it, have come at the cost of neglecting another phenomenon: being well. This is not to say that there are no other important worries associated with the concept. Some liberal and conservative critics have provided arguments for why the term needs to be, in their words, "put to sleep." Pointing to a utility disadvantage, conservative journalist David Brooks claims that "the problem with wokeness is that it doesn't inspire action; it freezes it. To be woke is first and foremost to put yourself on display. To make a problem seem massively intractable is to inspire separation-building a wall between 4. According to the metaphor, there is extrinsic value as well. Having this knowledge represents true freedom. On the other hand, while the blue pill provides a beautiful prison, it is still a prison nonetheless. 5. Kimberlé Crenshaw, "The Urgency of Intersectionality," TED, December 7, 2016, https:// www.youtube.com/watch?v=akOe5-UsQ2o. you and the problem-not a solution."6 Pointing to an epistemic disadvantage, NPR's Sam Sanders claims that the problem is that "we've made woke a rigid state of being instead of a process of continual growth. For that reason . . . let's put woke to sleep."7 I think these claims are tenable. However, these worries are related more to the misuse of wokeness rather than its uses. I take it for granted that those who are "growing in their wokeness" and are inspired towards action given their understanding of oppression are more vulnerable to threats to their well-being and are likely to neglect it as they pursue social and political solutions. Therefore, it is worrisome that the discourse deemphasizes well-being. I find the neglect interesting because there is a connection between being woke and being well. The connection is this: being woke can impede being well. If this relationship is neglected, then those who are trying to understand oppression and engage in productive action to end it, will eventually be consciously awake but perhaps psychologically, emotionally, and even physically asleep. I do not take this claim to be controversial or even novel. Scholars, writers, activists, and those in the medical profession mostly agree with me on this point. However, I will offer––if only briefly––three premises to support the view. First, being woke, with all its benefits, can cause existential pain. W.E.B. Du Bois in 1903 rhetorically engages the wokeness dilemma in the form of a depressing question when he asks "How does it feel to be a problem?" in the first chapter of The Souls of Black Folks. He goes on to argue that the second sight that Black Americans have "yields him no true consciousness . . . this double consciousness, this sense of always looking at one's self through the eyes of others, of measuring one's soul by the tape of a world that looks on in amused contempt and pity."8 This is the constant task of being aware 6. David Brooks, "The Problem with Wokeness," New York Times, June 7, 2018, https://www.nytimes.com/2018/06/07/opinion/wokeness-racism-progressivism-social-justice.html. 7. Sam Sanders, "Opinion: It's Time To Put 'Woke' To Sleep," NPR, December 30, 2018, https://www.npr.org/transcripts/680899262. 8. W. E. B. Du Bois, The Souls of Black Folk (New York: Vintage International, 1989), 3. Cherry PPJ 3.1 (2020) 3 of how others see you or will see you in your identity. This task does not only strip you of the existential freedom and pleasure to see yourself through your own eyes alone, but it limits your being to a subject (often a despised, inferior, or suspicious one) of constant gaze and investigation. How can one truly be oneself or think of oneself as such, when they have this consciousness? This is existential pain. Second, being woke to one's own oppression can also lead to mental pain. Take, for example, racial oppression. In an in-depth study, Robert Carter argues that racism can be a source of stress, trauma, and emotional injury.9 This race-based traumatic stress is defined as "emotional injury . . . racially motivated stressor that overwhelms . . . racially motivated, interpersonal severe stressor that causes bodily harm . . . that can cause fear, helplessness, or horror.10 Thompson-Miller and Feagin in their interviews with elderly blacks found that the blacks' memories of racist interactions produced responses that indicated race-based traumatic stress.11 They concluded that racial discrimination and other racial oppression can have a psychological impact that can last a lifetime. Janssen and colleagues found that in the UK and the Netherlands, people with high rates of psychosis are chronically exposed to discrimination.12 Feagin and Sikes also recognize how dealing with racism saps energy from subjects. Sighting a prominent black clinical psychologist they write: Now a black person also has one 9. R. T. Carter, "Racism and Psychological and Emotional Injury: Recognizing and Assessing Race-Based Traumatic Stress," The Counseling Psychologist 35, no. 1 (2007): 13-105. 10. Thema Bryant-Davis, "Healing Requires Recognition: The Case for Race-Based Traumatic Stress," The Counseling Psychologist 35, no. 1 (2007): 135-43, 135. 11. Ruth Thompson-Miller and Joe R. Feagin, "The Reality and Impact of Legal Segregation in the United States," in Handbooks of the Sociology of Racial and Ethnic Relations, edited by Pinar Batur and Joe R. Feagin (Boston: Springer, 2007). 12. I. Janssen, M. Hanssen, M. Bak, et al., "Discrimination and Delusional Ideation," British Journal of Psychiatry 182, no. 1 (2003): 71-76, https://doi.org/10.1192/bjp.182.1.71. hundred ergs; he uses 50 percent the same way a white man does, dealing with what the white man has [to deal with], so he has 50 percent left. But he uses 25 percent fighting being black, [with] all the problems being black and what it means.13 This energy that is sapped by dealing with a hostile world, is energy that could be used for family interactions and creative projects. This has material consequences. If being woke to sexist, homophobic, or classist oppression can sap energy then a person loses precious energy that she needs to live a flourishing life. Third, the complete awareness found in being woke that Cras alludes to also comes with a burden. Baldwin urges folks he describes as "relatively conscious whites" and "relatively conscious blacks" to insist on and create the consciousness of others. And he says that we have a duty to do so. "For if we do not," says Baldwin, "like lovers, insist on, or create, the consciousness of others-do not falter in our duty. . .. If we do not dare everything . . . the fulfillment of that prophecy . . . is upon us . . . the fire next time."14 Now this is not just a warning to others who are resistant to having this awakening of consciousness. Moreover, it is also a weight––a weight placed on the shoulders of those who are already awake. This turns Du Bois's question upside down: How does it feel to be the answer to a problem? In addition, having the above burden of awakening and challenging others is not just the activity of bringing them to account but it also consists of having some form of faith in humanity that the person will change. And it's this faith that leaves one vulnerable to certain loses, such as the pain of disappointment. Also the best efforts to persuade people to act morally can fail and in turn make one's life go worse. This can leave a person at the risk of being mistreated, again. As Ryan Preston-Roedder writes: Someone who has faith in humanity is vulnerable in certain respects 13. Joe R. Feagin and Melvin Sikes. Living with Racism: The Black Middle-Class Experience (Boston: Beacon Press, 2006), 295-96. 14. James Baldwin, The Fire Next Time (New York: Vintage International, 1993), 105-06. Cherry PPJ 3.1 (2020) 4 to losses she will incur if people in whom she has faith turn out to be base, or if they have acted, or will act, wrongly . . .. She may suffer the pain of disappointment when people in whom she had faith, and whose behavior is salient to her, commit serious wrongs. And if she makes personal sacrifices in order to encourage people to act rightly, but these people act wrongly instead, the fact that her efforts fail can, by itself, make her life go worse, quite apart from any emotional pain it causes her.15 Lastly, the aforementioned act of challenging, which consciously aware folks engage in, requires certain virtues. However, these virtues may not lead to a flourishing life. Lisa Tessman argues that certain virtues that the oppressed take on such as courage are virtues in the context of injustice. They enable survival in the midst of oppression. But they also come at a moral cost. They are "burdened virtues" in that they interfere with our ability to achieve moral goodness and they can distract from our well-being. On her view, courage, for example, may be a burden for those who are woke in that "courageously accepting the many possible risks and sacrifices in the life of a committed political resister, puts a burden on the self" and it may lead to a painful, self-sacrificial life.16 Being woke does not just affect those who are the direct victims of injustice and oppression. Woke allies can also bear a cost. Baldwin makes this point above by noting the burden of both black and white conscious ones. And I think Tessman would also agree that not only the oppressed but those in solidarity with them may take on burdened virtues as they fight against injustice. However, although a person can be in solidarity with those who are the direct victims of an injustice, this does not mean that she experiences the same threats to her well-being. Threats do vary in kind and degree. But the point that I want to highlight for our purposes is that being woke has no respect of persons when it comes to compromising being well. 15. Ryan Preston-Roedder, "Faith in Humanity," Philosophy and Phenomenological Research 87, no. 3 (2013): 664-87, 669. 16. Lisa Tessman, The Burdened Virtues (New York: Oxford UP, 2005), 127. Although being woke can cause existential and mental pain; comes with a burden; and may impede a flourishing life, these should not be reasons to descend back into Plato's cave––a metaphorical place in which one prefers to live a life in which the shadows of illusions are their new reality; a place where they think they live in a world in which inequalities are a thing of the past––in order to dodge these harms. Instead, I think this provides reasons to conclude that being woke is not enough. Perhaps one must not only beware of injustices but be aware of each other. Perhaps one should not only resist injustice but restore, repair, and reaffirm each other. One must make being well a priority, too. I shall argue for the rest of this paper that this can only happen when those who are aware of injustice and are committed to addressing it take care of those who are similarly woke in this respect. (I expand, more specifically, on who these agents are in section 3). In section 2, I claim that the ways in which care can be extended is through what I call solidarity care. After providing an account of solidarity care, I provide, in section 3, pragmatic ways in which one can extend solidarity care to others. I conclude in section 4 by responding to two possible worries. 2. Solidarity Care What exactly is Solidarity Care? Let's begin first by looking at solidarity. Simply speaking, solidarity is unity or mutual support and recognition. There are five core normative requirements for solidarity according to Tommie Shelby, and robust group solidarity exists where these five characteristics are exhibited: 1) Members identify with each other to the point of treating fellow members as extensions of each other; 2) There is special concern and thus a disposition to assist and comfort members; 3) There are shared values and goals between members that can take the form of social visions, ideals, or policies; 4) Members have loyalty to each other and faithfulness to the group's values; and lastly 5) There is mutual trust between members. But any form of solidarity will also have content. For Shelby, this content is defined by the goals the group embrace as being a member Cherry PPJ 3.1 (2020) 5 of the group. For example, the content of black solidarity, on Shelby's account, is unfair social disadvantage because of blackness. Solidarity with the group then is about "identifying, correcting, and ultimately eliminating race-based injustices."17 I have argued elsewhere for vulnerable solidarity; a solidarity whose content is unfair targeting, social death, and incarceration of social groups who are always vulnerable to being next in line for such treatment. It's a solidarity that is about correcting and eliminating such treatment.18 As I see it, the content of solidarity and its aboutness seem to traditionally show that solidarity by itself has as its primary focus the issue and in correcting it. Members' loyalty to each other is based on the ideals of the group; special concern is to assist members in the work of the group; trust is in order to contribute to the values of the group. But what about the members? What are our obligations to them not as fellow fighters but as humans? Their individual needs are worth responding to––not as a means to accomplish a grand objective––but because they are worthy of our care. Now this is not to say that Shelby's account is not concerned with members. However, I think my account makes caring more central. While care has been neglected in liberal theory, feminist philosophy has recognized its moral significance. Care ethics is in some ways the opposite of liberal theory. The liberal tradition asserts the importance of the individual and views the individual as a self-made person in need of their rights being respected without interference from others. The feminist care tradition, on the other hand, recognizes that we are dependent on one another to survive although this level of dependence varies. Our lives being better or worse depends on how we respond to and interact with each other. It is our relationships that shape us and also have life-altering effects. These relationships call us to be atten17. Tommie Shelby, We Who Are Dark: The Philosophical Foundations of Black Solidarity (Massachusetts: Harvard UP, 2017), 151. 18. Myisha Cherry, "State Racism, State Violence, and Vulnerable Solidarity" in Naomi Zack's (ed) The Oxford Handbook of Philosophy and Race (New York: Oxford University Press, 2017). tive to each other.19 Care ethics reminds us of the importance of caring for and caring about each other. As Maureen Sander-Staudt writes, "care ethics involves maintaining the world of, and meeting the needs of, ourselves and others. It builds on the motivation to care for those who are dependent and vulnerable."20 Taking all of this together, solidarity care, then, prioritizes not issues but caring for and about each other with the goal of making members be and stay well––given the reality of the issue (i.e., social injustice). It is not a replacement for existing solidarity. It is an essential and even necessary complement to other kinds of group solidarity. It's Shelby's normative requirement number two (special concern) on steroids but informed by different motivations. Who are the targets of solidarity care? The phrase "member of a group" should not be taken to only refer to members of institutional or racial groups, for example. A person can be in solidarity with another person and this solidarity need not be rooted in any affiliation at all. Marco can be in solidarity with Femi based on an unjust incident in which Femi was victim to (e.g., Femi suffered abuse by his boss). Marco need not be in solidarity with everyone who suffers like Femi. As long as Femi and Marco fulfill the normative requirements that Shelby describes, they are targets of solidarity care. In this way, we can get rid of the term "group" and replace "members" with Marco and Femi. Is it possible to be in solidarity with those who are either ignorant of your solidarity or who reject it? This is too big a question to answer in this paper. However, I do not have to answer it fully to make my argument. My argument for solidarity care and how to extend it presupposes that the relationship between parties is such that there is mutual awareness of members' solidaristic commitments (although this awareness can vary in degree) and members do not reject the solidary, instead, they have certain expectations (and justifiably so) of it. In addition, Marco need not be in solidarity with 19. Lori Gruen, Entangled Empathy (New York: Lantern Books, 2015). 20. Maureen Sander-Staudt, "Care Ethics," The Internet Encyclopedia of Philosophy, December 27, 2019, https://www.iep.utm.edu/. Cherry PPJ 3.1 (2020) 6 Femi on every issue. He may be in solidarity with Femi around the unjust incident, but not in solidarity with him around a wrongdoing that Femi perpetrated. However, as I will argue in what follows, since Marco is in solidarity with Femi in other areas, he can still extend solidarity care. So what does solidarity care look like in practice? In other words, how might we care about and care for others who are also awake, actively deprogramming themselves, and challenging oppressive systems? 3. Extending Care In what follows, I offer up three ways in which relatively conscious folks can extend solidarity care to others; however, these suggestions are in no way exhaustive. The first way that members can extend solidarity care is by figuring out how they are each other's problems and then stop being a problem. No matter how committed a person might be in her solidarity, there is always the possibility that ego, privilege, bias, and other "isms" can rear their ugly heads at any time. These things are difficult to let go of and they do not disappear because a person makes a decision to be in solidarity with others. However, if a person cares for and cares about those she is in solidarity with, she should not only focus on making sure outsiders are not inflicting pain on them. She should also make sure that she is not repeating the same actions and reproducing the same harms as oppressive others. In her critiques of second wave feminism, black feminist scholar Audre Lorde was constantly concerned about this "being a problem" phenomenon. Lorde recognized that although white feminists at the time championed feminism, they paid little to no attention to the experiences of poor women, women of color, or lesbian women. Lorde noticed that white women were engaging in the same exclusionary and inequitable actions of the patriarchy they were criticizing. She argues: Women of today are still being called upon to stretch across the gap of male ignorance and to educate men as to our existence and our needs. This is an old and primary tool of all oppressors to keep the oppressed occupied with the master's concerns. Now we hear that it is the task of women of Color to educate white women-in the face of tremendous resistance-as to our existence, our differences, our relative roles in our joint survival. This is a diversion of energies and a tragic repetition of racist patriarchal thought.21 It is a mistake to think that because a person is "consciously aware" of race and it's problems that they are, by definition, also aware and awake to homophobia or classism. A woke person's ability to understand one issue does not equate to their epistemic or moral mastery of the other. Recall that this rigidity is what grounds Sander's critique of what I have described as a misuse of the concept "woke." We see examples of this lack of epistemic or moral mastery when we look at past and present social justice movements. Today, as in the past, there are, for example, members of the LGBTQI community who are in solidarity with other members but are also transphobic. We see this in the way that trans activists Sylvia Rivera and Marsha P. Johnson are often erased as key leaders in the history of LGBTQI liberation. We can also see this in the way in which marriage equality is often hailed as the pinnacle of LGBTQI rights while legislation that addresses the vulnerability of trans folks is seldomly advocated. And we also see this in the explicit transphobic actions that gays and lesbians engage in. This shows that "You too may be someone else's problem." Lorde recommends that white feminists who perpetuate racism "touch that terror and loathing of any difference that lives there. See whose face it wears." She suggests that only then "the personal as the political can begin to illuminate all our choices."22 Similarly, wherever your hate, intolerance, disgust, or indifference resides inside of you for those you say you are in solidarity with, face it and try to overcome it. Lorde is right, the master's tools will never dismantle the master's house. And this means that members cannot do what oppressors do if they want liberating results. I will also add that the master's tools will never create a home, a 21. Audre Lorde, Sister Outsider: Essays and Speeches by Audre Lorde (Berkeley: Crossing Press, 2007), 113. 22. Ibid. Cherry PPJ 3.1 (2020) 7 home where all solidaristic fellows are cared about and cared for. The second way that one can provide solidarity care is by reciprocating care. Reciprocity is mutual responsiveness. This does not mean that one ought to care for others in the exact ways, at the same time, or to the same degree that others care for them. I do not think this is always possible. One reason is due to the fact that people are in different positions of power and privilege and thus have access to different levels of resources to share. However, although reciprocity can never be exact, it should still be extended. If members are in solidarity with each other, care should not be one-sided. When there is mutual responsiveness, a person does not feel taken advantage of. Instead, he feels appreciated. He feels that his concerns matter, that he is loved, that he has support. This feeling helps create security and a much needed healthy sense of importance. What can lead one to neglect this form of reciprocity? What is the cause of this "caregap"––a slit in reciprocity between members of solidaristic groups?23 A person can widen the care gap when they think that their issues are the most important ones. This is an example of the proverbial Oppression Olympics-a competition where people view their individual pain or struggle as the worse struggle and therefore ordain it as the pressing issue of our time. By doing so, they neglect caring for others who may face different issues. In addition, failure of reciprocity care can indicate, or at the very least, communicate, that they believe only certain lives are worth fighting for. This is not merely neglect. It is lack of care that arises out of a sense of superiority. Recent examples of this can be found in The Movement for Black Lives and in recent criticisms of a lack of feminist solidarity as it relates to black and white women. The Movement for Black Lives was founded by black lesbian women who wanted to bring attention to the physical and social deaths of 23. In Black Girls Matter: Pushed Out , Overpoliced, and Underprotected (New York African American Policy Forum, 2015), Kimberlé Crenshaw refers to it as 'asymmetrical solidarity." black and brown bodies of all backgrounds–– deaths that were at the hands of state actors. However, the police brutality cases that got massive media attention and galvanized people, were cases involving black boys and black men. The deaths of black cis and trans* women were almost completely ignored by black activists and, not surprisingly, the larger public. What often occurred, unintentionally by the founders, was that the narrative began to center black boys and black men at the exclusion of black cis and trans* women. This communicated to many that the black lives that really mattered when it came to police violence were boys and men. But if we consult the recent archive of the movement, we will find that it was black women who started the hashtag and started the organization. It was women who marched against police brutality in protest through cities across the nation. It was women who got behind podiums, case after case, holding back tears as they represented the deceased and unfortunately the black community at press conferences. Women showed up for the movement, but people rarely showed up for them. Reciprocity was lacking, making the care gap quite wide. In response, black feminist academics and activists started the #SayHerName campaign. It's an initiative that acknowledges that "although black women are routinely killed, raped, and beaten by the police, their experiences are rarely foregrounded in popular understandings of police brutality . . . [the campaign seeks to] respond to increasing calls for attention to police violence against black women by offering a resource to help ensure that black women's stories are integrated into demands for justice, policy responses to police violence, and media representations of victims of police brutality." Women's default was to engage in this kind of self-care because they did not get the reciprocity care they needed. This should not be when others purport to be in solidarity with them. The #SayHerName campaign was created not as a response to minimize the reality of black male death or to steal attention away from that reality. It was created to say that black women suffer too. It proclaimed: Acknowledge us, like we acknowledge you! Cry for us, like we cry for you! Fight for us, like we fight for you! Cherry PPJ 3.1 (2020) 8 There are other examples of this care gap. In January of 2017, women of all backgrounds descended on Washington, D.C. and other places around the world to protest the misogynistic language and actions of the incoming U.S. President. One of the most popular photographs from the event, depicts an image of a black woman, Angela People, with a sign that says: "Don't forget: White women voted for Trump," as she stands in front of a group of young white women dressed in all pink. According to interviews with People, the sign was not meant to sabotage the march, be divisive, or a downer in a moment of feminist affirmation. It was a sign that expressed a lack of reciprocity care. On People's view, 95 percent of black women fought against the incoming politician in the voting booth. However, white women did not. Maybe it was because they had other interests. But the point was: Black women showed up for themselves and other women, but white women did not show up for them. Reciprocity care was lacking. It is examples like this that give reason to women of color to view white feminists with suspicion, leading journalist Jenna Wortham to write: "while black women show up for white women to advance causes that benefit entire movements, the reciprocity is rarely shown."24 This creates distrust––a distrust between two communities whose liberation depends on this solidarity and trust. However, we can learn from this. When people show up for you, you should also show up for them. This is how you care for others. The third way that one can extend solidarity care is through affirmation and encouragement. In present-day social discourse, valuing how people speak to each other has been termed, pejoratively, as political correctness. And a person who values such things are labeled snowflakes or cupcakes. On the other hand, the ability to say particularly destructive speech is, by some people, hailed as the American right of free speech. It's the right that tough people exercise. 24. Jenna Wortham, "Who Didn't Go to the Women's March Matters More than Who Did," New York Times, January 24, 2017, https://www. nytimes.com/2017/01/24/magazine/who-didnt-go-to-the-womens-march-matters-morethan-who-did.html. However, if being woke has the mental effects that I claim it does in section 1. (regardless of one's sensitivity level), then affirmation and encouragement are not luxuries or coddling. Solidarity care is a necessity. The work of psychologists show us that what we believe about ourselves on the subconscious level can have an impact on outcomes. Their work also shows that affirmation and encouragement provide a buffer to stress, particularly the racial and sexual traumatic stress that many experience. It can be stressful to be awake in a world that reminds you and others that you are in solidarity with––through rhetoric, policy, entertainment, and laws––that your life does not matter; that you are cursed, a mistake, a freak, or inferior. However, being presented with counter evidence of this through affirmation, confirmation, and encouragement is both a form of care and resistance against such destructive claims. A person can fight for freedom and still not be free because she can eventually––if not believe these messages––be in such a vulnerable position that the words can beat, defeat, and burden her. Destructive words have harmful mental and physical effects that threatens one's overall health. However, affirming through counter-speech can help block these effects. This way of extending care is what made Malcolm X so appealing. Many may disagree with the rhetoric and arguments of the early Malcolm X, but one of the many things that the black community adored about him was his use of language. His words allowed them to feel like they were still human. His words affirmed the black man who was getting beat by the cops on the streets of Harlem. His words sowed a seed of love to the black woman who felt disrespected by life. His defense of blackness made the unemployed young person feel that there was still hope. This is because affirmation has this power. If a person cares for others, she will not only speak words to power but she will also speak words that will empower others. Consider the affirmation James Baldwin offers to his namesake in a letter to his nephew: Please try to remember that what they believe, as well as what they do and cause you to endure, does not testify to your inferiority but to their inhumanity and fear . . . [later on he says] this is your home . . . do not be Cherry PPJ 3.1 (2020) 9 driven from it. . . it will be hard . . . but you come from sturdy peasants . . . men who picked cotton and damned rivers . . . and in the teeth of the most terrifying odds, achieved . . . a monumental dignity.25 Consider the affirmation and encouragement Martin Luther King, Jr. gives to members of SCLC in one of his most radical speeches, "Where Do We Go From Here?": And with a spirit straining toward true self-esteem, the Negro must body throw off the manacles of self-abnegation and say to himself and to the world, "I am somebody. I am a person. I am a man with dignity and honor. I have a rich and noble history, however painful or exploited . . . yes, yes we must stand up and say "I am black but I'm black and beautiful. This self-affirmation is the black man's need, made compelling by the white man's crimes against him.26 Consider the encouragement of black Congresswoman Maxine Waters spoken in a MSNBC interview after white TV personality Bill O'Reilly demeaned her for her black hair: And I'd like to say to women out there everywhere: Don't allow these rightwing talking heads, these dishonorable people, to intimidate you or scare you. Be who you are! Do what you do!27 This is why social media hashtags such as #RefugeesWelcome, #TransIsBeautiful, #BlackExcellence, and #BlackGirlMagic are so needed and powerful. They are viral expressions of care. Their users express them in order to affirm and encourage those who may be hearing opposing messages. While validation and affirmation are important, providing it in response to fragility should 25. James Baldwin, The Fire Next Time (New York: Vintage International, 1993), 10. 26. Martin Luther King and Cornel West, The Radical King (Massachusetts: Beacon Press, 2015), 170-71. 27. Joseph Hinks, "Maxine Waters to Bill O'Reilly: 'I'm a Strong Black Woman and I Cannot Be Intimidated," Time, March 29, 2017, https://time. com/4716111/maxine-waters-bill-oreilly-fox/. be avoided. I will use "white fragility" as an example. Robin DiAngelo describes white fragility as "a state in which even a minimum amount of racial stress becomes intolerable, triggering a range of defensive moves. These moves include the outward display of emotions such as anger, fear, and guilt, and behaviors such as argumentation, silence, and leaving the stress-inducing situation."28 In white fragility, whites seek racial comfort (when they are challenged for example) instead of tolerating racial stress. White fragility can occur when a white person in solidarity with people of color receives feedback that their behavior had a racist impact. In displaying white fragility, they can come to feel guilty or angry thinking that the group now takes them to be racist and they get defensive. DiAngelo suggests that the behavior functions to reinstate white racial equilibrium. They push back to regain their racial position. Their resistance ensures that racism itself will not be faced by means of protecting their moral position while deflecting accountability. This defensiveness is also steeped in a perception of white arrogance, white purity, and racial comfort. However, validation goes wrong when people respond to white fragility by affirming the above behavior. This can occur by telling the white person "it's not your fault" or "everybody's a little racist." This also happens when a person responds by validating or affirming their response of denial and resistance by saying "You are right to feel this way" or "You don't have to take this." In this way, the fragile person and the affirmer can engage in the perpetuation of white supremacy. I think the correct response in these moments is not validation or verbal comfort but criticism. In this way, Marco can provide solidary care to Femi when he criticizes Femi's racist behavior even though he is not in solidarity with Marco in relation to his racist behavior. And this leads me to my next suggestion. A person can provide care for another's moral well-being by challenging them to be morally better through criticism. This is because being 28. Robin DiAngelo, "White Fragility," International Journal of Critical Pedagogy 3, no. 3 (2011): 54-70, 57. Cherry PPJ 3.1 (2020) 10 well is not just about feeling better. It is about being and doing better. Baldwin had no problem criticizing America because he knew it was an act of care. He understood that criticism that was grounded in truth and aimed at accountability was essential to care. He writes: "I love America more than any other country in the world, and, exactly for this reason, I insist on the right to criticize her perpetually."29 When people care for you, they tell you the truth about yourself. The caring criticism that I am concerned with here always aims to be constructive and not (negatively) destructive. A caring critic aims to correct and help change problematic behavior. He does not aim to tear down but to build up anew. There is much debate in the activist community about calling in and calling out, when to do it, and which approach is best in certain circumstances. I do not have time to deal with these debates here but I do want to note that a caring critic is not motivated by things like moral grandstanding. Caring––not attention––is the goal. 4. Conclusion In closing, I want to address two possible worries. Some may be concerned that I have only focused on human beings in this essay at the neglect of nonhuman animals and the environment more generally. And so the thought might be, that the only solidarity that I think truly matters is our solidarity with humans, and this sounds untenable. However, this is not what I am arguing. I think that we also need to figure out how we are being a problem to other species and stop being a problem. I also believe that the world gives us so much beauty, sustenance, and connection and we need to reciprocate that care as opposed to treating nature like the giving tree-taking and giving nothing in return. The environment is already in solidarity with us. Some of the questions I think we need to ask ourselves before we can tackle the care question in this domain is: Can we acknowledge its 29. James Baldwin, "Autobiographical Notes," in Baldwin: Collected Essays (New York: The Library of America, 1998), 9. solidarity with us and are we truly willing to be in solidarity with it? (These are questions that I do not think are restricted to this relationship.) Some might also be concerned that I have neglected self-care. And they may think I have done so because I do not think it's important. And this is unfortunate since self-care is often times the only care option that oppressed people have access to. However, I think when people use the term selfcare, they often use it in the narrow sense of the individual taking responsibility for their own health. In popular usage, it's used to account for the ways a person mentally, spiritually, and physically tends to their own needs––needs that are often sacrificed for others' needs. So self-care is a person following the airplane instructions of first taking care of themselves before they take care of others. The idea is that if you are not well, you cannot help others be well. Audre Lorde believed in the power and need for self-care and she claims that it is not an act of self-indulgence but of "self-preservation and that is an act of political warfare."30 I also think that self-care is of utmost importance in spite of my non-emphasis above. However, I do not think that self-care is a sufficient condition of well-being. More importantly, I think that we should view self-care differently than we often tend to. Self-care is never done independently. Someone has to watch the kids as you meditate. Someone teaches the yoga class that relaxes you. Someone gifts you with the book that is changing your life. A therapist or friend listens to your story. A friend shows you how to make the green juice. Self-care takes place in community. Even if and when we decide to take care of ourselves, someone else is always joining in. The challenge that I have hoped to motivate throughout this essay is: Are you willing to provide the same care to others? Let's return back to the epigraph by Audre Lorde that begins this essay: "Without community there is no liberation, only the most vulnerable and temporary armistice between an 30. Audre Lorde, Burst of Light and Other Essays (New York: Ixia Press, 2017), 130. Cherry PPJ 3.1 (2020) 11 individual and her oppression."31 Lorde reminds us that freedom is not freedom from others. Without community there is no liberation. But I also think that without caring for others that we are in solidarity with––providing solidarity care––we will never truly be free or well, no matter how woke or aware we think we are. Acknowledgments I am indebted to the audiences at the 2017 Race and Health Conference at University of Washington; 2018 Black Religion, Spirituality, and Culture Conference at Harvard University School of Divinity; 2019 Public Philosophy Network Conference at Michigan State University; and 2019 Public Philosophy Conference at Boston University for their thoughtful and invaluable questions, comments, and suggestions. References Baldwin, James. "Autobiographical Notes." In Baldwin: Collected Essays, 5-10. New York: The Library of America, 1998. ---. The Fire Next Time. New York: Vintage International, 1993. Brooks, David. "The Problem with Wokeness." New York Times, June 7, 2018. https://www. nytimes.com/2018/06/07/opinion/wokeness-racism-progressivism-social-justice. html. Bryant-Davis, Thema. "Healing Requires Recognition: The Case for Race-Based Traumatic Stress." The Counseling Psychologist 35, no. 1 (2007): 135-43. Carter, R. T. "Racism and Psychological and Emotional Injury: Recognizing and Assessing Race-Based Traumatic Stress." The Counseling Psychologist 35, no. 1 (2007): 13105. Cherry, Myisha. "State Racism, State Violence, and Vulnerable Solidarity." In The Oxford Handbook of Philosophy and Race, edited by Naomi Zack, 352-62. New York: Oxford UP, 2017. 31. Audre Lorde, Sister Outsider: Essays and Speeches by Audre Lorde (Berkeley: Crossing Press, 2007), 112. Cras, Raven. "What Does It Mean to be Woke." Blavity News, September 26, 2015. https:// blavity.com/what-does-it-mean-to-bewoke/what-does-it-mean-to-be-woke?category1=opinion. Crenshaw, Kimberlé. "The Urgency of Intersectionality." TED, December 7, 2016. https:// www.youtube.com/watch?v=akOe5-UsQ2o. Crenshaw, Kimberlé, Priscilla Ocen, and Jyoti Nanda. Black Girls Matter: Pushed Out, Overpoliced, and Underprotected. New York: African American Policy Forum and Center for Intersectionality and Social Policy Studies, 2015. DiAngelo, Robin. "White Fragility." International Journal of Critical Pedagogy 3, no. 3 (2011): 54-70. Du Bois, W. E. B. The Souls of Black Folk. New York: Bantam Books, 1989. Feagin, Joe R., and Melvin Sikes. Living with Racism: The Black Middle-Class Experience. Boston: Beacon Press, 2006. Gruen, Lori. Entangled Empathy. New York: Lantern Books, 2015. Hinks, Joseph. "Maxine Waters to Bill O'Reilly: 'I'm a Strong Black Woman and I Cannot Be Intimidated.'" Time, March 29, 2017. https:// time.com/4716111/maxine-waters-bill-oreilly-fox/. Janssen, I., M. Hanssen, M. Bak, et al. "Discrimination and Delusional Ideation." British Journal of Psychiatry 182, no. 1 (2003): 71-76. https://doi.org/10.1192/bjp.182.1.71. Kelley, William Melvin. "If You're Woke You Dig It." New York Times, May 20, 1962. https:// www.nytimes.com/1962/05/20/archives/ifyoure-woke-you-dig-it-no-mickey-mousecan-be-expected-to-follow.html. King, Martin Luther and Cornel West. The Radical King. Massachusetts: Lantern Books, 2015. Lorde, Audre. Burst of Light and Other Essays. New York: Ixia Press, 2017. ---. Sister Outsider: Essays and Speeches by Audre Lorde. Berkeley: Crossing Press, 2007. Cherry PPJ 3.1 (2020) 12 Merriam-Webster, s.v. "woke (adj.)." Accessed June 5, 2020, https://www.merriam-webster.com/dictionary/woke. Preston-Roedder, Ryan. "Faith in Humanity." Philosophy and Phenomenological Research 87, no. 3 (2013): 664-87. Sander-Staudt, Maureen. "Care Ethics." The Internet Encyclopedia of Philosophy, December 27, 2019. https://www.iep.utm.edu/. Sanders, Sam. "Opinion: It's Time To Put 'Woke' To Sleep." NPR, December 30, 2018. https:// www.npr.org/transcripts/680899262. Shelby, Tommie. We Who Are Dark: The Philosophical Foundations of Black Solidarity. Boston: Harvard UP, 2017. Tessman, Lisa. The Burdened Virtues. New York: Oxford University Press, 2005. Thompson-Miller, Ruth and Joe R. Feagin. "The Reality and Impact of Legal Segregation in the United States." In Handbooks of the Sociology of Racial and Ethnic Relations, edited by Pinar Batur and Joe R. Feagin, 20313. Boston: Springer, 2007. Wortham, Jenna. "Who Didn't Go to the Women's March Matters More than Who Did." New York Times, January 24, 2017. https:// www.nytimes.com/2017/01/24/magazine/ who-didnt-go-to-the-womens-marchmatters-more-than-who-did.html. Contributor Information Myisha Cherry is Assistant Professor of Philosophy at the University of California, Riverside. Her books include The Moral Psychology of Anger (coedited with Owen Flanagan) and UnMuted: Conversations on Prejudice, Oppression, and Social Justice (Oxford). She is also the host of the UnMute Podcast-where she interviews philosophers about the social and political issues of our day. Current Publication, 27 January 2020: https://publicphilosophyjournal.org/full-record/?amplificationid=2113 Journal Publication, 30 March 2020: https://publications.publicphilosophyjournal.org/record/?issue=6-18-224915&kid=6-15-