UN Population Division, Department of Economic and Social Affairs,
with support from the UN Population Fund (UNFPA)
|
| UN Population Division, Department of Economic and Social Affairs, with support from the UN Population Fund (UNFPA) |
|
***********************************************************************
POPULI -- The UNFPA Magazine
Vol. 22, No. 8 -- December 1995
This is a text-only version of POPULI, a magazine published
quarterly by the United Nations Population Fund (UNFPA).
POPULI
UNFPA
220 East 42nd Street
New York, NY 10017, USA.
Fax: (212) 557-6416
Editor-in-Chief: Stirling Scruggs
Editor: Abid Aslam
Contributing Editors: Alex Marshall, Hugh O'Haire
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and Spanish. Copies may be obtained from your local UNFPA office or
United Nations Information Centre, or from the address above.
We welcome your views. Please address letters to the editor or e-mail to
<aslam@unfpa.org>.
We also welcome submissions. For our writers' guidelines, address
a letter to the editor or e-mail to <aslam@unfpa.org>.
Articles appearing in POPULI may be freely reproduced so long as
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your needs, please contact us so we can put you in touch with the
authors.
CONTENT -- DECEMBER 1995
IN BRIEF -- News in brief.
NEWS -- STD treatment and AIDS prevention; Gender-biased health
research; Housing in South Africa; Mexico's midwives; Choice,
equality, and statistics in India.
FEATURES:
The "Agenda for Women's Empowerment" -- An adapted summary of key
sections of the Beijing Declaration and Platform for Action adopted
by the Fourth World Conference on Women.
Not to be Beaten Down, by Suzanne Hanchett -- At the NGO Forum in
Huairou, China, grassroots groups shared concerns including
reproductive and environmental health. But two issues stood out as
universal and held out the greatest promise of galvanizing the
women's movement in all its diversity: violence and economic
injustice.
VIEWPOINTS:
The Great Transition -- The International Conference on Population
and Development saw a shift in emphasis, away from demographic
targets and in favour of meeting the needs of individuals. Steven
W. Sinding and Mahmoud F. Fathalla of the Rockefeller Foundation
outline the policy and programme implications of this shift.
RESOURCES -- Publications, products, and prospects.
NOTEBOOK -- Promises made at Beijing.
=====
> IN BRIEF
Unlikely Allies
In the wake of September's Fourth World Conference on Women,
Zambian women fighting for emancipation have found an unlikely ally
in traditional chiefs. Custodians of tradition, chiefs are known
for allocating agricultural land to men and condoning the
expropriation of widows by their late husbands' relatives. Now,
seven traditional rulers in the northern province of Luapula have
launched a campaign to educate their subjects on issues of gender
equality, literacy, access to credit, property rights, gender
violence, the feminization of poverty, and the young girls' rights
to, for example, education. The campaign has grown out of a
workshop for chiefs, headmen, and community court judges. "The
involvement of traditional rulers is cardinal in the fight for
equal rights," project coordinator Daisy Seketeni told Inter Press
Service. The project will be extended to other provinces until all
traditional rulers are involved, she added. The Gender Planning
Department of the National Commission for Development Planning has
identified traditions and customs as some of the root causes of the
inequality, abuse, and discrimination women suffer. Community court
judges are being included in the workshops because they administer
justice according to customary laws which often allow abusive
husbands to go unpunished while societal pressure forces battered
women to tolerate abuse rather than face the shame of divorce,
especially since wife-beating is considered normal in many
traditional circles.
Teen Abortion Boom
Abortions are on the rise among Russia's teenagers, according to
the country's Family Planning Association. At three million, the
number of abortions overall is more than twice the number of
births, according to an Association report carried by the ITAR-Tass
news agency and monitored by the Associated Press. Though no exact
figure was given, the number of abortions among girls aged 17 or
less is believed to have doubled over the past five years. Although
imported modern contraceptives are now available, only some 23.5
per cent of Russian women were using them last year, according to
surveys. Reasons for this are thought to include: price; continued
preference for abortion inherited from times when contraceptives
were of poor quality; an economic climate in which children
represent a significant financial burden on their parents; and
limited education on sexuality in Russian schools.
Rosie the Riveter?
South Korea's Kumho Business Group has become the country's first
corporation to establish regulations against sexual harassment. The
rules follow a survey of 900 of the group's 3,100 female workers:
One in four complained of male colleagues' verbal or physical
sexual advances. The rules are "mainly aimed at protecting female
workers who are relatively vulnerable to sex-related incidents at
workplaces," Kumho official Kim Jae-Myung told Agence France
Presse. Workers will have the means to report discrimination or
harassment. If allegations are confirmed, offenders will have to
apologize in public and will risk dismissal. Another Kumho official
said the rules could make for a less "amicable" workplace.
This follows the Seoul government's announcement that it will
enact anti-discrimination legislation. In an October address to the
32nd National Women's Congress, President Kim Yong-sam promised the
government "will eradicate discriminatory elements against women,
which are deeply rooted in every corner of our society, by
legislating a basic law elevating the social status of women,"
according to a Yonhap news agency broadcast monitored by the
British Broadcasting Corporation. Kim said the government plans to
"introduce a women's employment target system in the public sector
so that more competent females will be employed as civil servants
and staff members of government-invested enterprises" and to
encourage the private sector to follow suit. The government also
plans to promote women's education and vocational training and to
expand child-care services. "A borderless economic war is being
waged, and the participation of women in modern working society
will significantly boost the country's international
competitiveness," Kim was quoted as saying.
Silencing America
America's poor are at risk of being removed even further from the
political process by legislation that would stifle the voices of
non-governmental organizations (NGOs). At stake is some US$240
billion in federal grants to such organizations -- 75 per cent of
it to non-profit health, family planning, and reproductive health
groups. Led by Representative Ernest Istook of Oklahoma, right-wing
Republicans in the US Congress are promoting legislation that would
prevent or severely limit federal funding of NGOs "carrying on
propaganda or otherwise attempting to influence" legislation,
public policy, or government agencies' work. Thus, say critics, the
legislation effectively would prohibit local housing, social
service, or health groups from filing law suits, conducting action-
or policy-oriented research, conducting volunteer registration
drives, or merely associating with other groups deemed to be
spending more than 15 per cent of their budget or US$25,000,
whichever is greater, on "advocacy." Most troubling to groups such
as the National Family Planning and Reproductive Health
Association, the proposed legislation would penalize a federally-funded
organization, regardless of the extent of federal funding it
receives, even if it funds its "advocacy" from private sources.
Foes of the proposed legislation have dubbed it the "Silence
America Amendment." If passed in its current form, it would also
apply to US-based relief organizations operating abroad, according
to Inter Press Service.
Botswana Victory
In a case that went up to the Botswana Court of Appeal, the Student
Representative Council of Molepole College of Education has struck
a blow for women's rights, successfully suing to overturn a college
regulation penalizing pregnant students. The Court's ruling is the
second landmark decision in support of women's rights in recent
years and brings new pressure for reform of discriminatory laws,
according to an account in the [Journal of African Law]. Under the
regulation, a pregnant student had to "inform the Dean as soon as
pregnancy is confirmed and...not more than three months after
conception" and was forced to leave school for a year. The
regulation also penalized any student concealing a pregnancy and
prescribed expulsion for any student becoming pregnant for the
second time while at college. The college principal could grant
exceptions to the rule. The student council argued before the High
Court that the regulation was unfair, unreasonable, and in
violation of constitutional guarantees of fundamental rights and
protection against discrimination. But the High Court let the
regulation stand on the grounds that it was written to provide the
student with a well-planned maternity leave. The Court of Appeal
rejected that view and the argument that a year's enforced absence
from college was comparable to the three months' "confinement
leave" granted civil servants. Furthermore, the Court found that
the real purpose of the regulation was to punish unmarried
students: When asked whether a married student would have to leave
school for a year, the Attorney General answered that the Principal
would make an exception in such a case. The Court also found that
the threat of punishment was held over the heads of unmarried
female students with no equivalent liability for their male
counterparts. Writing in the [Journal], E. K. Quansah cites another
landmark ruling of some three years ago and comments: "This trend
of acute awareness of women's issues in a male-dominated judiciary
is welcome. Unfortunately, the same awareness does not seem to have
permeated government circles as there has been a very slow response
to the bold initiatives taken by the judiciary on behalf of women."
Life With Choice
The International Planned Parenthood Federation (IPPF) has adopted
a new charter implicitly endorsing a woman's right to safe abortion
to terminate an unwanted pregnancy, according to press reports.
About 400 delegates from 140 countries unanimously approved the
charter in November, at an IPPF conference in Manila, Philippines.
The new charter embodies 12 rights, including "the right to life
which means, among other things, that no woman's life should be put
at risk or endangered by reason of pregnancy," according to a
conference statement quoted by the Reuters news agency. The charter
recognizes "that all persons must be free to enjoy and control
their sexual and reproductive life and that no person should be
subject to forced pregnancy, sterilization, or abortion." Delegates
noted that of the 50-60 million women who have abortions each year,
20 million endanger their health because they are forced to seek
unsafe abortions, according to the DPA news agency. Although the
charter does not actually say women have the right to choose safe
abortion, "that is implied," V.P. Palan, IPPF's regional director
for East and Southeast Asia and Oceania, told Reuters. Delegates at
the Manila conference called on governments to devote more time and
resources to sexuality education and family planning programmes,
arguing that abortion would not be necessary if there were no
unwanted pregnancies, according to DPA.
Does Development Spread AIDS?
Governments and development agencies should consider the effect on
the spread of AIDS of infrastructure projects such as road
construction and hydro-electric dams. This according to Nkosazane
Zuma, South Africa's health minister and vice-chair of the board of
UNAIDS, the new Joint United Nations Programme of HIV/AIDS. Dr.
Zuma acknowledged research findings that highways constructed under
national development plans with international financing had become
conduits not only of cargo but also HIV. She noted that one of
apartheid's legacies is South Africa's system of migrant labour,
under which workers spent months and sometimes years at a time away
from home. For apartheid's economic policy-makers, the system
seemed a perfect means of procuring cheap, unattached labour to
fuel economic growth. But it also provided a perfect medium for HIV
transmission. "I don't think anyone has worked out concrete ways of
factoring AIDS prevention into infrastructure or economic
programmes and projects," she said, adding: "Just as there are
gender impact assessments, there should also be AIDS impact
assessments" of such projects. Speaking at a press conference on
women and AIDS at the NGO Forum in Huairou, China, she added: "If
we are to control AIDS, women must have access to reproductive
health services, reproductive rights, and sexual rights." Asked if
UNAIDS had plans to promote or design such AIDS impact assessments,
board chair Sally Shelton said no but added that the agency "hasn't
really been born yet." UNAIDS is due in January.
-Abid Aslam
=====
> NEWS
STD Treatment and AIDS Prevention: On target, but no 'magic bullet'
Scientists are being cautious in welcoming research claiming that
the incidence of HIV, the human immunodeficiency virus, could be
"almost halved" if other sexually transmitted diseases (STDs) are
treated effectively. Nevertheless, the findings have caused
speculation that STD control and treatment programmes in developing
countries may be in for a funding boost.
While the existence of STDs has long been seen as a key factor
in the spread of HIV, a new study provides firm evidence of this
for the first time. The study, carried out over three years by
British and Tanzanian researchers, involved the provision of low-cost drugs
to people with STDs in Mwanza, Tanzania. The improved treatment of STDs
led to a decrease in the incidence of HIV transmission -- or the number
of new cases of infection -- by about 40 per cent in rural areas.
Many STDs cause sores, ulcers, or inflammation to appear on
the genitals of men and women. It is these that make it easier for
HIV to leave one person's bloodstream and enter another's during
unprotected sexual intercourse.
As many as one million Tanzanians are HIV-positive, according
to the government. While the study offers little consolation to
those who already have HIV, its authors believe that their work has
important implications at home and abroad.
"The demonstration that HIV incidence can be almost halved by
a modest intervention in one of the world's most disadvantaged
countries should provide a message of hope," according to the
study, published in [The Lancet], a British medical journal.
Experts welcome the research but express caution in
interpreting its results. "This is a valid and very useful study,"
said Chandra Mouli of the World Health Organization's (WHO) Global
Programme on AIDS, "but it is important to remember that even if
all other STDs were wiped out from the face of the earth, HIV would
continue to spread, albeit at a reduced rate."
Dr. Mouli's comments were echoed by Tony Klouda of the
International Planned Parenthood Federation (IPPF). "This is an
important, well done, and honest study, but my gut reaction is that
it won't make a significant difference in terms of HIV reduction,"
Dr. Klouda argued. "AIDS is a symptom of underdevelopment. It shows
up where health services are weak, where women's position is weak,
where employment opportunities are limited. Unless you deal with
those conditions, you won't make a substantial difference to the
spread of HIV."
Nevertheless, the results of the Mwanza research project
appear to demonstrate an impressive reduction in HIV incidence. In
the groups receiving improved treatment for STDs, 1.2 per cent of
patients became infected with HIV over the period of the trial. In
the control group not receiving treatment, the figure was 1.9 per
cent.
The project operated in 12 large communities and involved the
training of staff from health centres, the establishment of a
central STD reference clinic, and the regular supply of drugs to
treat STDs effectively. More than 12,000 people were recruited for
the study.
Key to the project's success was the low cost of treatment.
Rather than use the most powerful treatments which cost around
US$10 per dose, the team used high dosages of much cheaper drugs
such as Septrin, a two-day course of which costs about 70 cents.
Also important was the training given to staff at health clinics.
"Health workers have tended to treat STD patients as naughty
children," said David Mabey, a professor at the London School of
Hygiene and Tropical Medicine and member of the research team. "We
spent a lot of time getting workers to have a welcoming attitude
towards patients, and also conducted publicity campaigns in
villages to let people know that these services were available."
Mabey said he believes the methods used in the project are
potentially replicable on a larger scale in Tanzania and in many
other developing countries. "We have calculated that...treating
every patient who demonstrates symptoms of STDs in Tanzania using
our approach could cost as little as US$2 million," he said.
But there were limitations to the approach, he added. "Septrin
is effective now, but may not be effective in two years' time and
may not be useful in other parts of the world. It is important to
monitor constantly the effectiveness of drugs."
Funding boost for STD programmes?
Nevertheless, he speculated that the evidence from Mwanza
could lead to increased funding for STD treatment programmes in
developing countries. "No one really knows how effective AIDS
education programmes are in containing HIV," he said. "We do
however now have firm evidence that this approach to containing
STDs does work in reducing HIV transmission."
In a letter sent to [The Lancet], however, WHO argued that an
over-reliance on STD treatment programmes would be a mistake.
"It is important that comprehensive STD management be
implemented in combination with interventions to change sexual
behavior," the letter stated. "While not wanting to diminish the
results, we are concerned that STD treatment alone may be viewed as
the 'magic bullet' of AIDS prevention."
There are wider concerns, too. "The patterns of STDs are very
different in different parts of the world," Mouli said, "and
individual STDs vary in the efficiency with which they facilitate
transmission of HIV. There are also financial and logistical
reasons why such interventions will not always work."
What's more, according to IPPF's Klouda, although the Mwanza
project may have been implemented at low cost, this does not
address the more complex questions of how to deliver treatments
effectively.
"A measles vaccine costs a couple of cents but millions still
die from the disease," Klouda said. "The problem is not just that
of treatment, but also of establishing the infrastructures that can
get health services to those who need them."
The most difficult problem for the widespread implementation
of STD treatment programmes is that up to 90 per cent of STDs do
not cause symptoms and, therefore, sufferers do not seek treatment.
"While medical technologies such as condoms and STD treatment
are extremely important and must be developed," Mouli argued, "it
is essential that approaches such as this do not sideline the other
two pillars of AIDS prevention, education and motivation of people
on the one hand, and the empowerment of vulnerable groups such as
women, on the other, to protect themselves from HIV."
The experts do not doubt the importance of the Mwanza study in
providing firm evidence of why HIV has spread so fast in many
developing countries, particularly those with the poorest access to
health services. As the study stated: "The magnitude of the effect
on HIV incidence is the clearest evidence to date that a large
proportion of HIV infections in the population are attributable to
the...effect of STDs."
-James Deane/PANOS
Gender-biased health research: Finding a hidden disease
Although schistosomiasis in the vagina was identified a century
ago, only now are the chronic tropical disease's particular effects
on women receiving scientific scrutiny.
Most troubling to researchers is evidence that the disease may
facilitate the transmission of HIV, the human immunodeficiency
virus, from men to women and contribute to infertility in women.
Schistosomiasis, also known as bilharzia, affects some 200
million people in 74 countries. It is produced by a water borne
flatworm which is parasitic in blood vessels in the human pelvic
region. An estimated 9-13 million people may be affected by the
genital lesions that are among its most common symptoms, but it
remains "a hidden disease," particularly where women are concerned,
according to Hermann Feldmeier of Germany's Institute of Tropical
Medicine.
"Women do not like to speak about it since symptoms and signs
are easily confused with those of sexually transmitted diseases,"
Dr. Feldmeier said. Partly because of this silence, but mainly
because of gender bias in scientific enquiry, most health workers
do not know how the disease manifests itself in women. Vaginal
schistosomiasis was identified in Egypt in 1899 but has been
neglected ever since, he said.
The costs of this neglect have been significant. In Malawi
alone, some four in ten people are affected by the disease,
according to health and population ministry estimates. The disease
is so common in some areas that people ignore it and consider it
normal for people, and especially children, to have blood in their
urine, according to the ministry's Newton Kumwenda.
Apart from blood in the urine, general symptoms include
tiredness and diarrhoea. Women often bleed heavily, and most forms
of schistosomiasis lesions bleed spontaneously and are easily
injured by sexual intercourse, birth, and medical examination.
"The warts increase the risk of contracting HIV in sexually
active women," Dr. Kumwenda said. "They create open wounds through
which the virus can easily be transmitted." But, he added, "when
the warts are treated for schistosomiasis, they disappear."
Yet, the disease could be the most common cause of infertility
among women in Malawi, according to Lester Chitsulo, the ministry's
chief research officer.
The fact of the matter, according to these researchers, is
that they still know too little.
"The pathophysiology and immunology are imperfectly
understood, appropriate diagnostic tools are not at hand,
therapeutic rationales do not exist, the natural history is not
well known, and women's perception of their illness has never been
studied," according to Feldmeier and three co-authors of a recent
paper in [Tropical and Geographical Medicine].
Since the bilharzia parasite is carried by a tiny snail which
lives in shallow water, dams and irrigation schemes often are
responsible for creating new areas of habitat. Dr. Chitsulo
attributes the bilharzia problem in the capital, Lilongwe, to
construction of the Kamuzu Dam. And since drawing water, washing
clothes, and other such chores are still overwhelmingly women's
work, women are thought to be at particular risk of infection.
Yet, women rarely come forward to say they are infected,
according to Agnes Kamanga of the Queen Elizabeth Central Hospital
in Blantyre. "What usually happens is that the disease is diagnosed
during routine check-ups," she said. This means that if diagnoses
are offered at all, they are limited to women who go to the
hospital for a check-up in the first place.
Furthermore, women's genital warts and lesions can be
overlooked or mistaken for symptoms of a sexually transmitted
disease, Kumwenda said.
Lorenzo Savioli, a doctor based in Tanzania, recalled the case
of a young girl sent to him by a village leader who thought her
symptoms were of a sexually transmitted disease. A young boy in the
neighbourhood had been wrongly accused of sexually assaulting her.
Gabriele Poggensee, a member of Feldmeier's research team who
last year directed the first prospective study of genital
schistosomiasis and now works at the Kilimanjaro Medical Centre in
Tanzania, found that Malawian women themselves frequently believed
they acquired the disease through sex.
Other possible consequences of the lesions for women include
delayed puberty, protracted menopause, ectopic pregnancy, anaemia,
miscarriage, cervical cancer (though this is not proven),
destruction of the hymen and clitoris, and incontinence. These are
certain to affect women's social standing and lives, but "there is
no data" on such non-clinical aspects of the disease either,
Kumwenda said.
Researchers expressed hope that their work will result in
better treatment for women in the future. But in their paper,
Feldmeier and his colleagues pointed out: "The conclusion of our
endeavour is that research on tropical diseases from a gender
perspective is necessary, warranted, and should be scientifically
rewarding."
-Angels Mtukulo/PANOS
South Africa: A vote is not a house
Outside Johannesburg's World Trade Center, where African ministers
met in October to prepare for next year's Second United Nations
Conference on Human Settlements (Habitat II), the South African
Homeless Peoples Federation (HPF) had built a house.
Their goal: to illustrate what could be done with a government
housing subsidy of up to $4,000.
Ironically, the house -- which was demolished after the
conference closed -- was the only project for which the
organization of homeless men and women had received any government
support. None of its 20,000 members had yet qualified for the
subsidy, which is available to anyone earning less than $216 a
month, a pittance in urban South Africa.
"We are showing the world that given the chance, poor people
can build their own houses," said Bernedictor Mahlangu, one of the
builders.
Almost two years ago, South Africa's first democratic
government promised an end to the national housing backlog,
estimated at between 1.5 and 3 million units.
By October, Housing Minister Sankie Nthembi-Nkondo told
Parliament, only 10,163 houses had been built. The target had been
350,000 houses a year.
Department of Housing officials conceded that they had spent
only about 10 per cent of the current housing budget -- increased
by 80 per cent to $730 million in March.
The HPF "recognizes the national minister's commitment to a
people's process," according to a statement left on the window
sills of the house built at the World Trade Center. But it also
noted the obstructions of "her lieutenants -- consultants,
bureaucrats, and bankers."
Indeed, Nthembi-Nkondo's advisors said she is frustrated by
her ministry's bureaucratic mind set, largely inherited from the
former government. Speaking at the Johannesburg conference, the
minister maintained that "no housing project that is done without
the participation of the community will ever succeed."
As they built their sample house, members of the five-year-old
HPF said their plight reflects two home truths. First, regardless
of country, very few government schemes intended for the poorest of
the poor actually reach them. Second, it is invariably through
their own efforts that the poor secure housing.
Project Coordinator Iris Namo said HPF members were prepared
for these harsh realities by their close association with the
Bombay-based Slum Dwellers Association (SDA) of India.
During a visit to Bombay before the elections, members of the
SDA tempered the South Africans' expectations by pointing out that
after almost 50 years of democracy, countless Indians still live on
the pavements. "We have come to realize that a vote is not a house.
It is just an X on a piece of paper," Namo said.
The South African government housing subsidy scheme, available
on a sliding scale to people earning less than $1,000 per month
(with a maximum subsidy of $4,000 to the poorest among them) is
failing to deliver houses for a number of reasons, according to the
HPF. Procedures for applying for subsidies are cumbersome for
people who are barely literate, and applicants have to prove that
they have tenure to land. Squatters are thus effectively excluded.
Subsidies are usually paid not to prospective home owners but
to private developers, and only on completion of construction. With
no access to bridging finance, most people are unable to build
their own home. By the time the developers have taken their cut,
there is precious little money left for actual building.
The house at the World Trade Center, estimated to have cost a
little over $2,000 (without plastering, lights or water), was only
possible because of the "sweat equity" of those who built it, the
HPF pointed out.
South Africa is littered with "toilets in the veld," said
Namo, because money has gone to private developers who have only
been able to put up the barest structures with subsidy funds. A
Housing White Paper published last year argued that people should
be assisted in expanding these shells. But Nthembi-Nkondo has
publicly questioned providing inadequate shelters reminiscent of
what the old apartheid regime built for blacks. Instead, the debate
has shifted to whether or not to increase the housing subsidy, with
the attendant budgetary concerns.
In the HPF's view, the ministry should concentrate on how to
make money accessible to communities to undertake their own
building projects. The organization wants the subsidy scheme
scrapped. Instead, the government could provide land and
infrastructure, plus financing for low-interest loans that poor
people could use to build their own houses.
Members of the federation -- eight in ten of whom are women --
had saved about $100,000, with which they were able to leverage a
further $1 million from sources linked to the Catholic Church. The
money is used as a low-interest loan fund for building homes.
While they waited for a promised $2.7 million from the
government, members built 118 houses, with more under construction.
According to Mahlangu, who also heads the savings scheme at
Orange Farm, an informal settlement not far from Johannesburg, all
loans from the revolving fund have been fully repaid.
"People know that if you don't pay back, your sister won't be
able to build a house when she is ready to borrow," Mahlangu said.
-Colleen Lowe Morna/WFS
Mexico: Birth revolution
Midwives in Mexico's most remote areas are being credited with
helping the government to bring down maternal and infant death
rates and promote family planning.
Ten years ago, the Mexican Social Security Institute (IMSS, by
its Spanish initials) began a rural midwife programme in places
where transportation is virtually non-existent and people speak
only indigenous languages. The programme has helped to nearly halve
maternal mortality and reduce infant mortality by almost one-third,
according to official statistics.
In addition, the midwives are credited with signing up some 10
per cent of new users of contraceptives in the past three years. In
1994 alone, they cared for some 198,000 pregnancies, helping more
than 55,000 women to give birth at rural clinics and another 52,000
at home.
With some 80 per cent of Mexicans enrolled in its programmes,
the IMSS is the country's largest provider of public health
services. With support from the social development ministry's
National Solidarity Programme, the IMSS established community
health committees in the neediest 14 of Mexico's 32 states.
More than 8,000 volunteer midwives educate their communities
about preventive healthcare, act as liaisons for neighbours who
need subsidized medical assistance, and provide emergency
treatment. They fall into three categories: traditional birth
attendants, IMSS-trained midwives, and apprentices.
"We teach them to boil drinking water, wash vegetables, wash
their hands before eating, throw away garbage, and build latrines,"
said Maria Reyes Arias, a midwife in Tresquelites.
Reyes can't read or write, but she knows how to administer the
herbs that she raises outside her cabin and where to find the wild
plants that can ease headaches, bellyaches, or infant colic. The
IMSS encourages the midwives to use their knowledge of native
herbal remedies, and swaps modern for traditional healthcare
information.
Reyes, a widow living alone since her children grew up, got
involved when the local IMSS rural health promoter asked her to
participate. She makes a 40-mile trip to the regional medical
center in her state capital every two months to receive training in
midwifery, contraception, hygiene, and sanitation.
When she goes to take a training course or accompanies someone
on a hospital visit, she has to walk an hour from her community to
the highway where she can flag down a bus. Other rural midwives
have to walk for as much as five hours to reach public
transportation or a medical facility.
Their efforts are believed to have made a significant
improvement in medical care for Mexico's rural poor. "Closer and
closer work with the midwives has contributed to very important
achievements for women's health," according to an IMSS report.
Then there's their cultural role. "Here in the community, they
speak Tzeltal," said Guadalupe Moreno, the doctor in charge of one
of some 3,500 rural medical units. "That's why the midwife is from
the community and translates to us, because it is a very large
abyss that exists between the doctor and the patient. We have two
very distinct ways of thinking."
-Talli Nauman/WFS
India: Choice, please, and equality too
If only women in India could have just as many children as they
desire, the country would come substantially closer to stabilizing
its population. This according to the recently released report of
the National Family Health Survey 1992-93.
In order to stabilize population, the government hopes to
reduce fertility to replacement level: two children per woman. The
goal seems to be consistent with women's own wishes: Nearly half of
those with more than two children said their families were larger
than ideal. Although most women are having fewer children than did
their mothers, the average family still has more than three
children per woman. In the state of Uttar Pradesh, the figure is
close to five.
So what's stopping women from exercising their will? Lack of
choices.
Despite progress, girls remain less likely to attend and stay
in school than boys. Nationwide, 59 per cent of girls aged 6-14 are
in school, compared to 76 per cent of boys.
To reach school-enrolment age in the first place, girls must
buck the prevailing trend: The risk of dying between the ages of
one and five is 43 per cent higher for girls than for boys, one of
the greatest sex-based mortality differences in the world.
Schooling is cut off for a number of reasons. One of them is
marriage. It is illegal to marry before age 18, but in rural areas
one in three women aged 20-24 got married before age 15.
Despite the widespread desire to space their children, fewer
than six per cent of married women are using temporary modern
methods of contraception. Nearly 25 per cent of women are unaware
of such methods, which include the pill, intra-uterine devices,
injectables, and condoms. Others do not know where to obtain these
methods. The national family planning programme still relies
heavily on sterilization, a permanent method. Some 30 million women
have family planning needs that are not being met by current
programmes.
If most women lack the means to plan their families, they also
lack the means to start or add to them in safety. In the four years
preceding the survey, some four in ten women who had babies
reported receiving no antenatal care. Only 34 per cent received
medical care at delivery; 30 per cent of deliveries were attended
only by friends, relatives, or neighbours.
More than 100,000 women die every year from pregnancy-related
causes. One infant in 13 dies before reaching its first birthday.
One child in two is underweight; for every five children who weigh
less than they should, one is severely underweight. The situation
is worse in rural areas.
The National Family Health Survey 1992-93 was India's largest
population and health survey, according to a statement from the
Bombay-based International Institute of Population Studies, which
provided coordination. The Ministry of Health and Family Welfare
initiated the survey, which was conducted by various organizations
and population research centres in each state. Close to 90,000
women and 88,000 households were included in the survey, which
received technical assistance from the East-West Center and Macro
International.
=====
FEATURES
Beijing Documents: The "Agenda for Women's Empowerment"
-----
This article is an adapted summary description of the Beijing
Declaration and Platform for Action. It is not an official version
of either document. For more information about the documents,
contact: Secretariat for the Fourth World Conference on
Women/Division for the Advancement of Women, DC2-1240, United
Nations, New York, NY 10017, USA. Telephone: (212) 963-8034/3130.
Fax: (212) 963-3463.
-----
The morning after the Fourth World Conference on Women ended,
cleaning crews got to work early, carrying and sweeping away tons
of paper: press releases and conference newspapers, proposals and
counter-proposals, announcements and denouncements. For two weeks,
the 40,000-odd people attending the conference had pushed,
bartered, and touted these documents, finally to leave them behind,
as if consigned to the past. They left Beijing with the official
future: a 38-paragraph Declaration and 361-paragraph Platform for
Action that describe themselves as "an agenda for women's
empowerment."
As POPULI goes to print, the Beijing Declaration and Platform
for Action are being edited and printed for public distribution.
What follows is an adapted summary of key sections of the documents
based on an unedited advance version.
The Beijing Declaration
The Declaration recognizes that although the status of women has
improved over the past decade, "inequalities between women and men
have persisted and major obstacles remain." This situation is made
worse by deepening poverty, particularly among women and children,
"with origins in both the national and international domains."
States dedicate themselves "unreservedly to addressing these
constraints and obstacles" and reaffirm their commitment to the
equal rights of women and men and to building on the consensus
reached at previous UN conferences and summits, including those on
women, held in Nairobi in 1985; on children, held in New York in
1990; on environment and development, held in Rio de Janeiro in
1992; on human rights, held in Vienna in 1993; on population and
development, held in Cairo in 1994; and on social development, held
in Copenhagen in 1995.
States adopting the Declaration are "convinced that," among
other things: women's empowerment and full, equal participation in
all spheres of society, including decision-making and the exercise
of power, "are fundamental for the achievement of equality,
development, and peace"; women's rights are human rights; and these
rights include equality of opportunity and access to resources and
"the right of all women to control all aspects of their health, in
particular their own fertility."
What's more, states are determined to, among other things:
intensify efforts to achieve the goals of the Nairobi Forward-Looking
Strategies for the Advancement of Women, adopted at the 1985 conference
on women; promote women's economic independence; prevent and eliminate
all forms of violence against women and girls; and "ensure equal access
to and equal treatment of women and men in education and health care and
enhance women's sexual and reproductive health as well as education."
The Platform for Action
Chapter 1: Mission Statement
The Platform's mission is to be an agenda for women's empowerment
on the basis of shared power and responsibility between women and
men at home and work, in the nation and in the community of
nations. Equality between women and men is essential for equality,
development, and peace, the three themes of the conference. The
human rights of women and the girl child are an inalienable,
integral, and indivisible part of universal human rights. But for
the Platform's goals to be met, there will have to be an "adequate
mobilization" of resources, including new and additional ones.
Chapter 2: Global Framework
In 36 paragraphs, this chapter summarizes the condition of women
worldwide: the grave violations of their rights, whether at the
mercies of ethnic cleansing or "discriminatory attitudes"; their
roles and struggles as the heads of one in four households, a
disproportionate number of which are -- and continue to be pushed
further -- below the poverty line; and their under-representation
in even the most democratic regimes, for example. Paragraph 9
states that implementation of the Platform will take into account
cultural and religious factors.
Chapter 3: Critical Areas of Concern
This chapter outlines twelve interrelated areas that require urgent
attention: poverty; inequality in education and training;
inequality in health care; violence against women and the girl
child; the effects of conflict; participation in defining economic
structures and policies; power-sharing; mechanisms to promote the
advancement of women; human rights; mass media; the environment;
and discrimination against and violation of the rights of the girl
child.
Chapter 4: Strategic Objectives and Actions
There are 12 sections to this chapter, one for each critical area
of concern:
> Section A, on poverty, calls for economic policies, development
strategies, and laws that guarantee women's rights to economic
resources and enable women to overcome poverty within the framework
of sustainable development.
> Section B, on education, calls for equal access to education, the
eradication of female illiteracy, and the removal of barriers to
sexual and reproductive health education. Boys and girls are urged
to share family responsibilities equally.
> Section C, on "women and health," accounted for almost one-fourth
of the text in dispute when the conference began. Much of the
conflict -- on reproductive health, sexual health, and information
and services for adolescents, for example -- was settled by
invoking language agreed upon at last year's International
Conference on Population and Development (ICPD). But on the key
disputed issue of abortion, for example, Section C ended up going
further than the ICPD Programme of Action.
The first "strategic objective" of this section is to
"increase women's access throughout the life cycle to appropriate,
affordable, and quality health care, information, and related
services." In this context, it calls on "governments, in
collaboration with non-governmental organizations and employers'
and workers' organizations and with the support of international
institutions" to "recognize and deal with the health impact of
unsafe abortion as a major public health concern, as agreed in
paragraph 8.25" of the ICPD Programme of Action, which "states: 'In
no case should abortion be promoted as a method of family
planning'." Indeed, Section C reiterates the ICPD consensus, urging
parties to "reduce the recourse to abortion through expanded and
improved family-planning services" and emphasizing that "prevention
of unwanted pregnancies must always be given the highest priority
and every attempt should be made to eliminate the need for
abortion." Where abortion is necessary and legal, it "should be
safe." What's more, "in all cases, women should have access to
quality services for the management of complications arising from
abortion. Post-abortion counselling, education, and family planning
services should be offered promptly, which will also help to avoid
repeat abortions."
But paragraph 107(k) of the Beijing document goes further,
calling on governments to "consider reviewing laws containing
punitive measures against women who have undergone illegal
abortions."
Likewise, Section C builds on ICPD's assertion of a woman's
right to reproductive and sexual health by establishing "the human
rights of women including their right to have control over and
decide freely and responsibly on matters related to their
sexuality...free of coercion, discrimination, and violence."
And although this section notes the need for balance between
the rights and duties of parents and the right of adolescent women
to privacy and counselling in matters such as reporting sexual
abuse involving family members, it states that "in all actions
concerning children, the best interests of the child shall be a
primary consideration." Indeed, the document notes that
"counselling and access to sexual and reproductive health
information and services for adolescents are still inadequate or
lacking completely, and a young woman's right to privacy,
confidentiality, respect, and informed consent is often not
considered." This even though teen-age women "are both biologically
and psychosocially more vulnerable than boys to sexual abuse,
violence, and prostitution, and to the consequences of unprotected
and premature sexual relations," and "young men are often not
educated to respect women's self-determination and to share
responsibility with women in matters of sexuality and
reproduction."
Among the other concerns raised in this section are: unequal
access to and use of basic health resources; gender bias in
clinical and social research on and services for malnutrition,
infectious diseases, and other common health problems that affect
women and men differently; the lack of emergency obstetric services
in many developing countries; dwindling health expenditures; and
structural adjustment policies which "contribute to the
deterioration of public health systems."
> Section D, on violence against women, recognizes that women and
girls are subjected to physical, sexual, and psychological abuse in
all societies. In addition to the more obvious forms of abuse are:
forced sterilization, abortion, the forced use of contraceptives,
prenatal sex selection, female infanticide, and unwanted pregnancy.
Displaced and repatriated women, migrant workers, and women
hostages are especially vulnerable, as are women living in poverty,
under foreign occupation, and in war zones. The causes of violence
need to be studied and "integrated measures" taken to prevent it.
Among the measures needed is legislation against female genital
mutilation, prenatal sex selection, infanticide, and dowry-related
violence. Likewise, international treaties and agreements against
trafficking in women need to be strengthened and implemented.
> Section E, on the effects of conflict, calls for: women's
increased participation in conflict resolution and the subsequent
reconstruction; women's leadership in peace and security
activities; the conversion of military spending and machinery to
peaceful and development-oriented purposes; moratoria on anti-personnel
land-mines coupled with assistance in clearing mines; recognition that
rape is a ware crime; and protection, assistance, and training for
refugee and displaced women.
> Section F, on economic structures and policies, urges governments
to: guarantee the rights of women and men to equal pay for equal
work or work of equal value; review national income and inheritance
tax and social security systems so they no longer discriminate
against women; take "positive action" to ensure women's equal
access to resources, employment, markets, and trade, especially for
poor women; and eliminate occupational segregation and all forms of
employment discrimination. Labour laws should be used to protect
part-time, temporary, seasonal, and home-based workers; ensure that
women and men can choose between full- and part-time work freely
and equally; and support job-protected parental leave and benefits
for both women and men. Assistance to micro-, small-, and medium-scale
enterprises needs to be consolidated. This section also notes
that women's contributions to development are "seriously
underestimated," primarily because most women's work is unpaid,
undervalued, and under-recorded. To some degree, it also describes
the inequalities between men and women exacerbated by economic
globalization.
> Section G, on power-sharing, notes that women are under-represented at
most levels of government and in decision-making positions in most other
fields. In addition to by-now familiar calls for more women in leadership
positions, this section calls for the protection and promotion of the
equal rights of women and men to engage in political activities and to
freedom of association, including membership in political parties and trade
unions. It also calls for "gender balance" within the UN system. It
does not set specific targets for women's participation, however.
> Section H states that mechanisms to promote the advancement of
women are insufficient and need to be strengthened at national,
regional, and international levels. Responsibility for women's
advancement needs to be vested at the highest possible level of
government. "Gender perspectives" need to be integrated into
legislation, public policy, programmes, and projects. More and
better data and analysis broken down by gender are therefore
necessary.
> Section I, on human rights, calls for the "full implementation"
of all international human rights instruments, especially the
Convention on the Elimination of All Forms of Discrimination
Against Women; equality and non-discrimination under the law; and
"legal literacy." This section also takes into account the results
of the 1993 World Conference on Human Rights and the 1994
International Conference on Population and Development, with regard
to such issues as the right to decide the number and spacing of
children and to attain the highest standard of sexual and
reproductive health.
> Section J, on mass media, calls for the increased participation
of women in the media and gender-sensitive training for media
professionals, managers, and owners, "to encourage the creation and
use of non-stereotyped, balanced, and diverse images of women." All
this must be "consistent with freedom of expression," however.
> Section K, on the environment, identifies unsustainable patterns
of consumption and production as the major causes of environmental
deterioration and notes the lack of recognition and support for
women's contribution to conservation. Women, "including indigenous
women," should be able to participate at all levels of
environmental decision-making and evaluation. Likewise, mechanisms
to assess the impact of development and environmental policies on
women should be strengthened.
> Section L, on the girl child, notes that girls are less likely
than boys to survive into adulthood, go to school, have sufficient
nutrition, or have access to physical and mental health services.
It urges eliminating all forms of discrimination against girls,
including "negative cultural attitudes and practices." It also
states that girls and boys have an equal right to succession and
inheritance and calls on governments to enact legislation that
recognizes this.
Chapter 5: Institutional Arrangements
This chapter states that implementation of the Platform for Action
should lead to "fundamental change." Responsibility for
implementation rests "primarily" with governments but also with
public, private, and non-governmental institutions at the
community, national, regional, and international levels. Paragraph
293 describes the conference as one of "national and international
commitment and action. This requires commitment from governments
and the international community." It calls on "states and the
international community" to make specific "commitments for action."
(Many governments did make such commitments during the course of
the conference. For a short list, see "Notebook.") This chapter
also encourages international financial institutions to review
their policies and increase the number of women among their top
ranks, and calls on the UN and Bretton Woods institutions -- the
World Bank and International Monetary Fund -- to coordinate their
activities more effectively.
Chapter 6: Financial Arrangements
This chapter emphasizes the necessity of political commitment to
make available the human and financial resources needed to advance
women's lot. Indeed, it blames "slow progress to date in
implementing" the Nairobi Forward-Looking Strategies mainly on weak
political commitment and the resulting insufficiency of resources.
Henceforth, "a gender perspective" must be integrated into budget
decisions, and although existing budgets and policies will need to
be reshuffled, funding will also need to be mobilized "from all
sources and across all sectors."
=====
FEATURES
FEATURE
Women of the NGO Forum: Not to be Beaten Down
by Suzanne Hanchett
-----
Suzanne Hanchett, Ph.D. is a freelance writer and international
development consultant. She attended the NGO Forum as a
representative of the International Women's Anthropological
Conference.
-----
Some 30,000 women -- and a few men -- gathered in Huairou, an
hour's drive from Beijing, for the NGO Forum running parallel to
the Fourth World Conference on Women. They came from all over the
world, bringing with them concerns and agendas as diverse as the
languages they spoke and the merchandise -- baskets, jewellery, and
fabrics -- many sold in vigorous trading to defray the cost of
their journey. Some had met at previous UN women's conferences or
in Cairo in 1994, at the International Conference on Population and
Development. Others were on their first international journey.
The Forum served as a rallying point for caucuses trying to
influence the official Conference process: Some 3,000 participants
eventually moved from Huairou to Beijing to struggle with
Conference delegates on sensitive points of wording for the
official Platform for Action.
Equally important, the NGO Forum fostered an elaborate, nine-day
political and personal conversation about today's world and
women's place in it.
"Look at the world through women's eyes," the Forum motto
read. Given the diversity of the 'international women's movement'
-- and its division along racial, class, and geographical lines --
it was more a case of seeing the world through many women's eyes as
the first step in achieving unity in pursuit of common goals. They
did not have far to look to find shared concerns, including
reproductive and environmental health. But two issues in particular
seemed universal and held out the greatest potential for
galvanizing the movement in all its diversity: violence and
economic injustice.
Women from countries at war with themselves or each other, and
those from countries ostensibly at peace, shared similar stories of
violence and its effects. Women from Viet Nam spoke of infertility,
miscarriages, and "malformed children," the continuing legacy of
the war with the United States. Women from Rwanda and the former
Yugoslavia spoke of rape and torture by not only the enemy but
their own militia and officials and neighbours in refugee camps.
Women from the United States and Europe spoke of infertility,
miscarriages, and other forms of reproductive ill-health resulting
from injuries inflicted by husbands, boy friends, or fathers. Two
afternoon demonstrations adopted the style of Israeli and
Palestinian "Women in Black": Nepali women waved black signs
protesting rape, wife-beating, and other injuries to women while
another group of some 500 women stood silently for an hour holding
black signs rejecting all violence, war, and militarism.
The focus shifted rapidly to economics.
"Where is the peace dividend?" asked Winnie Byanyima of
Uganda. She was joined by Indian scholar and activist Gita Sen, who
bemoaned the fact that "governments that cannot feed their own
people can buy and sell large quantities of arms."
Economic globalization in general and economic reform policies
-- structural adjustment programmes (SAPs) in the South and
policies with similar effects on social spending and public-sector
assets in the North -- in particular were criticized as major
threats to women's economic rights and well-being.
One after another, professors of economics, farmers,
housewives, and labour organizers rose to voice their concerns. A
Thai unionist complained bitterly about her government's strategy
of enticing investors with offers of "cheap labour." Too much
manufacturing, another speaker said, depends on young, compliant
women with good education and little inclination to demand better
working conditions. As Helen O'Connell of Women in Development,
Europe (WIDE) put it, the integration of developing countries into
the global economy now means that women of the South can work for
the same companies as women of the North, but for lower wages.
Just as worrying to Puerto Rican social scientist Marcia
Rivera, most international trade nowadays is speculation, not
economic production. Her concern had resonance for one woman from
eastern Germany, who said: "We have almost no industry now. We're
all bankers and service providers."
Women from the South decried the harm wrought by SAPs, and
their grievances resonated with women from the North who have seen
their responsibilities increase as social services are cut and
family incomes decline. In both cases, the adjustments ostensibly
are a response to public sector indebtedness to the private sector
or external lenders. Salvadorean biologist and Baptist minister
Marta Benavides summed up the situation to applause when she told
the NGO Forum plenary: "External debt, we call 'eternal debt'."
Oblique documents, direct criticism
Women's dissatisfaction with global economic trends was only
compounded by the Beijing Platform for Action adopted at the
official Conference. A tough battle was fought, and lost, over how
to represent SAPs. The Platform did mention the need for research
into the human impact of SAPs, but it rejected language proposed in
an NGO Working Paper stating that SAPs "in particular impoverish
and overburden women who are forced to make an invisible adjustment
in terms of their time, a longer and intensified work day, the loss
of income...and the closure of basic public health and social
services on which women depend both as [clients or patients] and as
sources of waged employment...."
In stark contrast to the causality assumed in many NGO Forum
discussions, the official document refers obliquely to an uncertain
global economic climate, notes an increase in female poverty in
many regions, and expresses concern at a tendency to reduce social
spending. This led the NGO Economic Justice Caucus to accuse their
governments of actively obscuring and refusing to take action
against the causes of women's poverty and marginalization.
Not to be beaten down, women intensified their calls for fair
trade practices; gender analysis as a basis of economic policy-making;
economic and social investment policies that increase
women's share and control of resources; equitable distribution of
resources through fiscal reform; and national accounting systems
that recognize women's work, paid and unpaid.
They did not spare international development programmes funded
by foreign aid, either, blasting many of these as exploitative and
coercive, and tied to business with donor countries' corporations.
The Philippine DIWATA Foundation and other NGOs blamed recipient
governments for "graft and corruption in funds management and the
suppression of people's organizations...in the name of
'development'."
One solution discussed -- and one supported by some donors'
current strategies -- was to involve more grass roots organizations
in decisions about development goals and methods rather than
dealing only with governments and international institutions. Many
voices joined in the chorus for a greater role for "civil society"
by increasing NGOs' and women's role in decision-making at all
levels, a principle affirmed in the Platform for Action.
Just to be clear about what NGOs expect to come of their
increased role, one woman said: "What we want is distribution of
wealth, not distribution of poverty."
Achieving such goals will require strong leadership. Charlotte
Bunch, director of the US-based Center for Women's Global
Leadership, urged women to "put governments and the United Nations
on trial" and force them to honour their commitments. If they
cannot, or will not, move women's vision forward, she added, "we
must take leadership and do it anyway." But the question remained,
who actually can and will take this leadership?
Some expressed the hope that young people -- and in particular
"the girl child" -- will step forward. Others, such as Peggy
Antrobus, general coordinator of Development Alternatives with
Women for a New Era (DAWN), had pointed out during pre-Conference
meetings in New York that women from the "global South" --
marginalized communities in developing and industrialized countries
-- have asserted significant leadership in politicizing the issues
and offering a holistic vision of and personal commitment to macro-economic
change. A similar approach characterized an East Asian
women's "Alternative Development" declaration adopted in Tokyo and
presented at the Forum by Yayori Matsui.
In the Forum's closing hours, some women from developing
countries said again that they looked to feminists in Europe and
North America to be "ambassadors carrying our message" into centres
of power, including their governments and international
institutions such as the World Bank. But are women in the
industrialized countries heeding the call for leadership?
Western women, at least some of them, responded that,
preoccupied as they are with fights against the erosion of their
rights, national budget cuts, and rising religious fundamentalism,
they too were shut out of centres of power and had limited energy
for an international fight on behalf of women's economic rights or
peace. But one young woman from the US pledged her organization's
support. She was part of the population that some referred to as
"the South in the North": immigrants and women of colour working
for equality and dignity in the work place without the benefits of
media attention.
And thus the Forum ended, with varied perceptions shared and
new conversations begun. Winnie Byanyima summed up the situation
and mood: "The world is changing rapidly and there are many
uncertainties," she told her diverse Forum audience. "One thing is
certain, though. Ecologically and economically, we will all sink or
swim together."
=====
VIEWPOINTS
From demographic targets to individual needs: The Great Transition
by Steven W. Sinding and Mahmoud F. Fathalla
-----
Steven W. Sinding is director of population sciences at the
Rockefeller Foundation. Mahmoud F. Fathalla is its senior adviser
for biomedical and reproductive health research and the author of
an earlier article on contraceptive technology, "The Unfinished
Revolution," which appeared in the October 1993 issue of POPULI.
-----
The International Conference on Population and Development (ICPD)
was a triumph for those seeking an end to the great debate that has
plagued the population field since the first World Population
Conference at Bucharest in 1974: a debate between advocates of
development as a necessary precondition to sustained fertility
decline and the advocates of family planning to meet high demand
for fertility regulation which they believed to exist.
Most sensible analysts and advocates have understood for many
years that both development and contraceptive services contribute
to the achievement of replacement level fertility but, in the
international arena, a remarkably persistent gulf remained between
these two essentially academic positions. The practical result of
this continuing debate was ambivalence and ambiguity in many
countries about which approach to take.
The Cairo conference took giant strides toward resolving the
conflict by focussing attention on individual needs instead of
demographic targets. At Cairo, the nations of the world agreed that
governments should give special attention to the education of
girls, the health of women, the survival of infants and young
children, and, in general, the empowerment of women at the same
time that they provide comprehensive reproductive health services
to enable couples to achieve their reproductive goals and determine
freely and responsibly the number and spacing of their children.
They also identified unmet need for contraception as a key
indication that high quality reproductive health services,
including family planning, are a high priority. If governments
ensure that this basic package of social policies and reproductive
health services is in place, the Cairo consensus implies, they will
simultaneously make strides toward greater social equity and reduce
high rates of population growth.
Cairo's new approach has far reaching implications, for
policies, for programmes, for services, and for contraceptive
technology. Very little research has been done to establish how
individual unmet need could effectively replace the demographic
orientation in the field of population. Such research is of
paramount importance as the basis for so fundamental a change in
programme philosophy. Changing a way of thinking and behaving that
has grown up over 25 or 30 years of programme experience requires
careful thought and action lest we wind up doing more harm than
good.
Policy implications
The ICPD Programme of Action is very long on references to the
well-being of women and children and very short on statements that
imply any imperative to reduce high rates of population growth.
This has led some to wonder whether those responsible for setting
broad national development policies and the allocation of resources
are likely to commit as much money in the future to population and
family planning programmes as they have in the past (which, in any
case, has never been very much). Those who hold this view argue
that if family planning and reproductive health are seen as
individual welfare measures rather than part of broad development
goals and a response to a major global concern about population
growth, these services will compete only with other welfare
measures in the allocation of the limited resources available to
the social sectors.
The Cairo document, in fact, does not imply any contradiction
between the objective of meeting individual needs and national or
global demographic goals. The shift to individual need is simply an
acknowledgement that the solution to the population problem will
not be made primarily in government offices. The most important
decisions will be made by couples and individuals. Cairo asserts
that people are most likely to adopt a family planning behaviour
when they find that their specific reproductive needs are
adequately addressed.
In the midst of the debate that preceded Cairo, one of us
participated in an analysis to try to determine whether expressing
goals in terms of unmet need would result in lower levels of
contraceptive use than the levels stipulated by traditional
demographic targets. The analysis showed that in many of the
countries for which there were data on both unmet need and
demographic targets, unmet need appears to be high enough that
substituting it for demographic targets would not only not
compromise demographic goals, it would actually enhance the
likelihood of achieving those goals. In other words, by satisfying
the expressed needs of individuals themselves, national policies
are likely in most cases to achieve higher levels of contraceptive
prevalence than would be the case if governments pursued, even
aggressively, a top-down approach to achieve targets.
The evidence from surveys on the magnitude of the unmet need,
however, remains to be substantiated by prospective intervention
studies in field experiments or demonstrations.
Implications for programmes
The Cairo shift has important implications for how family
planning programmes are structured, managed, and evaluated.
The ICPD Programme of Action recommended, in paragraph 7.16,
that: "all countries should, over the next several years, assess
the extent of national unmet need for good-quality family planning
services and its integration in the reproductive health context,
paying particular attention to the most vulnerable and underserved
groups in the population...The aim should be to assist couples and
individuals to achieve their reproductive goals and give them the
full opportunity to exercise the right to have children by choice."
This recommendation embraces five principles for family
planning programmes: identification of unmet need; an emphasis on
quality; integration of family planning services in the
reproductive health context; a focus on underserved groups; and
voluntary choice.
The unmet need for contraception has been simply defined as
women or men who want no more children or want to space the next
birth, who are not presently using any method of contraception.
Currently estimated at 24 per cent in sub-Saharan Africa, 13 per
cent in Asia and North Africa, and 16 per cent in Latin America,
the total unmet need could be close to or in excess of 100 million
women.
In the spirit of Cairo's new orientation, the definition of
unmet need should be broadened beyond this simple quantitative
assessment, to include other unmet needs from a user's perspective.
For example, it should include people who are using but are
dissatisfied with their present methods of contraception, and those
who seek related basic reproductive health services.
Likewise, there is a need to have a fresh look at the
instruments employed by the Demographic and Health Surveys, the
successor of the World Fertility Survey. There is a need for a new
generation of "Demographic and Reproductive Health Surveys" that
focus on identifying and measuring, in a quantitative and
qualitative way, the unmet need for family planning in a
reproductive health context, that are simplified enough to be used
by countries with limited resources on a regular periodic basis,
that can highlight underserved population groups, and that can give
indications of possible programme abuse.
Under the old approach, field workers typically were required
to map their catchment areas, identify the contraceptive status of
each married woman of reproductive age, establish a register of
persons eligible for contraception, and set new acceptor or
contraceptive prevalence goals for specific periods of time. Under
the new perspective, the orientation would shift from eligible
couples or married women of reproductive age to clients with an
unmet need. To establish unmet need, field workers would be
required to gather one or two additional pieces of information,
beyond the information they now gather in their home visits. They
would need to ask about reproductive intentions as well as current
contraceptive use and, on the basis of that information, determine
whether or not a contraceptive need is being satisfied. They should
also seek information on experience with, or concerns about, side-effects of
methods, whether or not the client has discontinued use of a method, and,
if so, why.
In countries with good basic client record systems, national
estimates of unmet need could be used as the basis for setting
national programme objectives. But more important, at the level of
the individual field worker, unmet need would become the basis for
setting goals and, as far as supervisors are concerned, evaluating
performance.
If the more qualitative dimensions are then added so that
field workers define unmet need not solely in terms of use of any
kind of contraceptive but use of a method that responds to the
clients' individual desires and needs, one has the basis for
expanding services from simple contraceptive coverage to a quality
of care dimension.
One way of illustrating this issue is in terms of the special
problem of "drop-out" rates. Many developing countries experience
high rates of discontinuation of use of contraceptive methods.
Research reveals that while service availability and method supply
are often at the root of the problem, many so-called drop-outs
occur because of client dissatisfaction with the methods themselves
-- side-effects -- or with characteristics of the service
providers, such as rudeness, lack of information, infrequency of
visits, and so on. Assuming for the moment that they occur
primarily for these performance-related reasons rather than because
of lack of availability of services or supplies, the adoption of an
individual, rather than a target-based, approach could lead to some
significant changes in how field workers are trained, supervised,
and evaluated. Instead of being judged on the basis of "new
acceptors," for example, they might be evaluated in terms of
continuation rates. Instead of being told to enroll a certain
number of new clients per month or year, they would be told to make
sure they consult regularly with their clients to follow-up on
complaints, questions, or concerns about contraceptive methods.
Furthermore, the Cairo document, in paragraph 7.17, urged "all
governments to institute systems of monitoring and evaluation of
user-centred services with a view to detecting, preventing, and
controlling abuses by family planning managers and providers and to
ensure a continuing improvement in the quality of services." This
means that family planning programme managers should not only look
closely at units with poor performance, but also at "apparent
successes" which could, in fact, indicate abuses and violations of
people's freedom of choice.
Implications for service providers
For service providers, the new approach implies the need for
a lot of learning as well as "unlearning" to run a client-friendly
-- and specifically, woman-friendly -- rather than demographic-goal-oriented
service.
There is a need to substantially revise training programmes to
transmit new skills to service providers at all levels and to begin
to change the attitudes that define the "subculture" of the
programmes themselves. In addition to technical training on contra-indications
and method characteristics, field workers will need to
be much more intensively trained than they are now on commonly
experienced side-effects, rumours and misconceptions about
contraception, and how to deal with patient fears and concerns. In
addition to being providers, they must now more truly become
counsellors.
The shift from demographic targets to individual needs poses
another challenge, beyond the issue of quality of care: the need to
meet closely related reproductive health needs. As the ICPD
Programme of Action put it, in paragraph 7.13: "Family planning
programmes work best when they are part of or linked to broader
reproductive health programmes that address closely related health
needs."
Reproductive health care in the context of primary health care
was defined, in paragraph 7.6, to include: "family planning
counselling, information, education, communication, and services;
education and services for prenatal care, safe delivery and post-natal care,
especially breastfeeding, infant and women's health
care; prevention and appropriate treatment of infertility;
abortion...including prevention of abortion and the management of
the consequences of abortion; treatment of reproductive tract
infections; sexually transmitted diseases and other reproductive
health conditions; and information, education, and counselling, as
appropriate, on human sexuality, reproductive health, and
responsible parenthood. Referral for family planning services and
further diagnosis and treatment for complications of pregnancy,
delivery and abortion, infertility, reproductive tract infections,
breast cancer and cancers of the reproductive system, sexually
transmitted diseases and HIV/AIDS should always be available, as
required. Active discouragement of harmful practices such as female
genital mutilation should also be an integral component of primary
health care including reproductive health care programmes."
While implementation of the full reproductive health approach
will require substantially increased resources -- perhaps as much
as US$17 billion by 2000, according to Chapter 13 of the Cairo
document -- the beginning of its implementation does not have to
wait for the mobilization of all these resources. The development
of a reproductive health "mentality" is a basic first step for
family planning services, caring about the individual before
counting the numbers. As a second step, family planning services
can assess what other components of reproductive health services
they can incorporate within their existing capacity and resources.
In many situations, utilizing available capacity more efficiently
will allow more services to be offered. The third step is to
utilize additional resources, as they become available, to add
services for unmet needs.
Integration of reproductive health services into family
planning programmes should be done pragmatically. There will always
be a place for both categorical and integrated services. Services
should be integrated if integration makes their delivery more cost-effective.
Each country's situation must be judged on its own
terms. Integration should be distinguished from "bundling" of
services. Simply combining services is not necessarily integration,
and it is not necessarily effective. Moreover, the need for
comprehensive health care should not translate into an all or
nothing situation. Providing people with some elements of a service
is better than providing no service at all. Nor should integration
result in dilution of available resources. Rather, it should result
in more effective utilization of resources that are put together.
Basic questions will remain to be answered in specific country
contexts, to define the cost-effective reproductive health care
packages at the primary health care level.
Implications for contraceptive technology
To respond to the shift from demographic targets to individual
needs, a second contraceptive technology revolution must be
launched, driven by women's needs and women's perspectives.
The first contraceptive technology revolution was largely
driven by demographic considerations, with emphasis on the
development of methods according to their presumed demographic
impact. Desired criteria included effectiveness, convenience to the
provider rather than the user, and long duration of action.
For the second revolution, the field should adopt a more user-centred
-- and woman-centred -- approach. Demographic impact will
not be lost; rather, it will be enhanced. Listening to women and
responding to their expressed needs is likely to be one of the best
strategies for achieving demographic objectives.
Collaboration between the users of the technology and its
developers is essential. This requires creating a common ground,
better communication, and more trust through honest and
straightforward dialogue.
The need for methods which women can use to protect themselves
against sexually transmitted diseases, including HIV/AIDS, has
become particularly urgent. The need is for effective methods which
women can use and control without the necessity for partner
cooperation. It is possible that if such methods become available,
women will do better than men in compliance, providing more hope
for the control of the pandemic of sexually transmitted diseases.
Another need is for a once-a-month pill which women can use as
a menses-inducer. For some women, the menses-inducer would be a
needed back-up to barrier contraceptive methods, thus encouraging
wider use of the latter for protection against infections. A
menses-inducer would also be suited to the particular needs of
adolescents where the decision to contracept is often made post-coitally.
For biological reasons, women have to carry all the burden and
risks of pregnancy and childbirth. This, however, is no reason that
they should also carry most of the burden of fertility regulation.
A sustained research effort is needed if men are to have broader
contraceptive choices to enable them to share effectively in the
responsibility for fertility regulation.
This contraceptive development agenda requires the application
of advances in cell and molecular biology and bio-technology to
fertility regulation, and the mobilization of industry resources
for this major research and development effort.
In summary, if the spirit of Cairo is to succeed, family
planning programmes must begin to do a better job of treating
clients as the beneficiaries -- in the true sense of the word --
rather than as the objects of population policies. The implications
of the shift from demographic targets to individual need are far-reaching.
Family planning programmes should begin to strive for
these objectives. Achieving the higher quality of care implied by
these exhortations is far easier said than done. It is time to move
from rhetoric to action.
There is a need for mobilization of more resources at the
national and international levels. There is a need for both
learning and unlearning to be done. Of equal importance, a research
agenda should be set, funded, implemented, and acted upon to guide
this great transition.
=====
> RESOURCES
Primers for Power
The Women's Environment and Development Organization has produced
a series of primers on gender, environment, and international
economic issues. The series highlights strategies toward democratic
global governance, with each brief primer providing background and
topical information as well as practical pointers for those
interested in learning more or launching campaigns for change. The
series includes such titles as "Codes of Conduct for Transnational
Corporations: Strategies Toward Democratic Global Governance";
"Transnational Corporations at the UN: Using or Abusing their
Access?"; and "How Secure is Our Food? Food Security & Agriculture
Under the New GATT & World Trade Organization." Other topics
covered include intellectual property rights and biodiversity and
the decision-making structures of the World Bank and regional
development banks. For more information, contact: WEDO, 845 Third
Avenue, 15th floor, New York, NY 10023, USA. Telephone: (212) 759-7982.
Fax: (212) 759-8647. E-mail: <wedo@igc.apc.org>.
Advocacy Handbook
[Cairo, Beijing, and Beyond: A Handbook on Advocacy for Women
Leaders], published by the Centre for Development and Population
Activities (CEDPA) with support from UNFPA, sets out to help women
become leaders of development. It examines strategies for advocacy,
public relations techniques, alliance-building, and fundraising and
presents profiles of successful community and policy advocates. For
more information, contact CEDPA's offices in Egypt, India, Kenya,
Nepal, Nigeria, Romania, or the main office: CEDPA, 1717
Massachusetts Avenue, NW, Suite 200, Washington, DC 20036, USA.
Telephone: (202) 667-1142. Fax: (202) 332-4496. E-mail:
<cedpa_lh@cerf.net>.
Micro-enterprise Revisited
"What is disturbing about much of the recent enthusiasm for
micro-enterprise development for women is its promotion in the wider
context of neo-liberal market reform, particularly 'rolling back
the state,' the removal of welfare provision, and the dismantling
of all forms of labour protection. It is also widely seen as a
viable and less socially and politically disruptive alternative to
more focussed feminist organizational strategies. All the evidence
indicates that there are likely to be serious limitations on any
micro-enterprise strategy for poor women in isolation." So says
Linday Mayoux, author of [From Vicious to Virtuous Circles? Gender
and Micro-Enterprise Development], Occasional Paper 3 published by
the United Nations Research Institute for Social Development for
the Fourth World Conference on Women. Mayoux discusses the "serious
limitations": First, the success of micro-enterprise programmes for
poor women is "seriously constrained" by the lack of decent
housing, basic health care and infrastructure, and welfare
provisions such as child care. Second, for many poor women,
improved labour legislation and rights protections are likely to be
more important than micro-enterprise. Third, women's
entrepreneurship and the effectiveness of micro-enterprise
programmes are severely hampered by a lack of resources and power.
Mayoux notes: "We know very little about whether, when, and how
women are able to use increases in income to negotiate desired
changes in their lives. We know even less about the ways in which
individual change may translate into wider changes through
'demonstration effects.' In some cases both processes do occur, but
this is not automatic and can by no means be assumed. Without
measures to address gender inequality, micro-enterprise programmes
may merely increase women's workload and responsibilities without
increasing their control over income." Mayoux concludes that it is
"unlikely that micro-enterprise development will prove to be the
rosy 'all-win' solution assumed in much of the promotional
literature. Even in terms of narrow aims of increasing beneficiary
incomes, micro-enterprise development is unlikely to succeed for
the vast majority of poor women (rather than a small number of
better-off women) unless it is part of a transformed wider agenda.
There are particularly serious implications for any reliance on
micro-enterprise programmes as the main focus of any wider strategy
for poverty alleviation and change in gender inequality." For more
information, contact: UNRISD, Palais des Nations, 1211 Geneva 10,
Switzerland. Telephone: (41-22) 798-8400/798-5850. Fax: (41-22)
740-0791.
The Spoils of Wealth
As their incomes rise, Chinese people are eating more livestock
products, turning the country into a net importer of grain and
driving up prices all over the world. Within a span of two years,
China has gone from being a net exporter of eight million tons of
grain to being a net importer of 16 million tons. Over the past
four years, the incomes of some 1.2 billion Chinese have increased
by about half. Dependence on starchy staples such as rice has been
replaced by an appetite for livestock products. Consumption of pork
has risen from seven million tons in 1978, the year economic
reforms were launched, to around 30 million tons in 1994. Poultry
consumption climbed from 3.2 million tons in 1990 to 6.6 million
tons in 1994. Seafood consumption also is rising, adding to demand
for grain as more fish comes from fish farms, where they are fed
grain. And by 1994, 13 billion litres of beer were being drained
yearly. While most of the growth in demand for food is the result
of affluence, China's population also is growing by some 13 million
per year. As more people desert the countryside for jobs in the
cities, more farmland will have to be paved over to accommodate
housing, industry, and transportation systems. All this amounts to
a "wake-up call for a small planet," in the view of Lester Brown,
author of [Who Will Feed China?]. Brown makes a number of
suggestions to Chinese policy-makers, though he says they also
apply to the rest of the world. His main suggestions are: First,
stabilize population well below the projected 1.66 billion by
continuing to press hard for the one-child family. Second, boost
agricultural investment, including research focussing on specific
national needs. Third, formulate a national strategy to protect
cropland, including a transportation system centred on railways and
bicycles. And fourth, launch a national programme to improve the
efficiency of water use. For more information, contact: Worldwatch
Institute, 1776 Massachusetts Avenue, NW, Washington, DC 20036-1904, USA.
Telephone: (202) 452-1999. Fax: (202) 296-7365.
Middle East Context
[Family, Gender, and Population in the Middle East: Policies in
Context], a collection of papers, sets out to help correct the
"rather simplistic view" of population policy-making in the Middle
East and to "bridge the gap between...those advocating fertility
limitation to foster national development and preserve global
environmental resources, and those concerned about the protection
of the rights of women and the well-being of individuals,"
according to the editor, Carla Makhlouf Obermeyer of Harvard
University. Based on the proceedings of an international symposium,
the book sets out to: analyze "the political conditions under which
population policies are formulated and implemented, in particular
the legal, religious, and symbolic aspects of the relationship
between the state and the individual"; focus on "the constraints
that household/family structures represent for individual
behavior"; and consider "the extent to which health and family
planning services are effective in improving the well-being of the
populations they serve, while responding to the needs of individual
women." Released last month in the United States and due out next
month in the rest of the world, the book is published in hardback
priced at US$35.00 in the US and US$37.00/UKL25.00 in the rest of
the world by The American University in Cairo Press, 113 Sharia
Kasr el Aini, Cairo, Egypt. In the US, it is distributed by
Columbia University Press, 562 West 113th Street, New York, NY
10025, USA.
Women's Human Rights
[The Human Rights Watch Global Report on Women's Human Rights] is
a compilation of investigations by Human Rights Watch in 1990-95.
Its chapters examine rape as a weapon of war and a tool of
political repression; the sexual assault of refugee and displaced
women; abuses against women in custody; trafficking of women and
girls into forced prostitution and coerced marriage; abuses against
women workers; domestic violence; and reproduction, sexuality, and
human rights violations. Released in advance of September's Fourth
World Conference on Women, the book contains investigative findings
as well as general recommendations to governments, aid providers,
and international institutions. For more information, contact any
of the following Human Rights Watch offices: 485 Fifth Avenue, New
York, NY 10017-6104, USA. Tel.: (212) 972-8400. Fax: (212) 972-0905.
E-mail: <hrwnyc@hrw.org>. 33 Islington High Street, London N1
9LH, UK. Tel.: (171) 713-1995. Fax: (171) 713-1800. E-mail:
<hrwatchuk@gn.apc.org>. 15 Rue Van Campenhout, 1040 Brussels,
Belgium. Tel.: (2) 732-2009. Fax: (2) 732-0471. E-mail:
<hrwatcheu@gn.apc.org>. Gopher address:
<gopher://gopher.humanrights.org:5000>.
World Population Prospects
The United Nations has issued [World Population Prospects: The 1994
Revision], its latest estimates and projections of population and
other demographic information for the world and individual
countries. In addition to detailed data tables available since last
year, the publication offers more than 200 pages of analysis and
methodological description and features discussion of three issues
in particular: new fertility declines in Africa and Asia; the
demography of countries with economies in transition; and the
demographic impact of HIV/AIDS. For more information, contact:
Director, Population Division, United Nations Secretariat, Rm. DC2-1950, New
York, NY, USA.
=====
> NOTEBOOK
Promises, promises
"Governments have the primary responsibility for implementing the
Platform for Action," according to the Beijing document. At the
conference, NGOs led a campaign to win specific commitments from
governments. Here is a short list of some of the promises made:
Australia: address health inequalities for indigenous women
Austria: outlaw family violence; ensure women equality under the
Constitution
Belize: write laws protecting women from sexual harassment
Cote d'Ivoire: establish a development fund and bank for women in
agriculture and business; ensure 100% school enrolment for girls by
2000
Equatorial Guinea: enact laws to protect women in marital
separation, widowhood, inheritance, family planning, forced
marriage, and childlessness
Ghana: legislate to protect women's property rights
India: increase spending on education, especially for women and
girls, to 6% of GDP; establish a commissioner for women's rights
Latvia: appoint an official to monitor adherence to the UN
Convention on the Elimination of all forms of Discrimination
Against Women (CEDAW); amend childcare, mothers' welfare, and
related labour codes
Lebanon: increase women's decision-making positions to at least 30%
and women's ownership of wood plots around homesteads to 90% by
2000
Lesotho: lift restrictions barring women from credit and business
Liechtenstein: eliminate citizenship legislation that discriminates
against women
Luxembourg: open a centre for young women who have suffered
violence or sexual abuse
Mongolia: halve maternal mortality and reduce infant mortality by
one-third from 1990 levels by 2000
Nepal: develop laws granting women equal rights to ancestral property
Poland: fight women's unemployment and provide equal access to
management jobs
Singapore: offer home economics courses to male and female
students; encourage employers to support family life programmes at
the workplace
South Africa: ratify CEDAW; provide more shelters for battered women
Suriname: minimize harm done by economic crisis and structural
adjustment programmes (SAPs) to women and other vulnerable groups
Tanzania: revise or replace all discriminatory laws with non-discriminatory ones
Turkey: scuttle laws denying gender equality; increase women's
literacy by 2% by 2000
United Kingdom: increase childcare by 20% (50,000 places) by March 1996
United States: set up a White House Council on Women to implement
the Beijing Platform for Action and a six-year US$1.5 billion
initiative against domestic violence and other crimes against women
Venezuela: address and eliminate the causes of violence; guarantee
women's equal opportunity in science, technology, and culture
Zambia: increase women's access to credit; achieve parity between
girls and boys in school enrolment by 2005
-----
Sources: Chapter 5, paragraph 293, [Platform for Action adopted by
the Fourth World Conference on Women: Action for Equality,
Development and Peace, Beijing, 15 September 1995], unedited
advance text; "Summary of the Fourth World Conference on Women: 4-15 September 1995," [Earth Negotiations Bulletin], Vol. 14, No. 21;
Plenary speeches, press releases issued by the UN/Conference
Secretariat, delegations, and NGOs. The full list of commitments
made is available on the Internet at:
<http://www.igc.apc.org/womensnet/beijing/com1.html>.
=====