Public Health Magazine: Winter 1995, Vol.5, No.1
Features
Women's health takes center stage

ICPD Coverage Population policy's paradigm shift

The language and priorities of family planning programs have changed. Now, according to the overwhelming consensus reached in September at the International Conference on Population and Development (ICPD) in Cairo, the goals are "every pregnancy intended" and "every child wanted." Overall, the empowerment of women was a central theme of the meeting.

One of the Columbia School of Public Health's (CSPH) faculty to attend the conference, Lynn Freedman, J.D., M.P.H, explained that "population and family planning are no longer just about getting pills and condoms into poor countries or even into this country. The world has come to understand reproductive health as a change in women_s status. In a broad-brush way, Cairo did that."

There were also discussions about the implications of rapid population growth in some of the poorer countries and its negative impact on social and economic development. But while all five faculty members who attended the ICPD view it as a watershed event, they also expressed concern that these advances are now threatened by the U.S. elections this past November. The U.S. played an important leadership role at this conference, as Vice President Al Gore attended, championing the new approach and committing greater U.S. resources.

If, indeed, U.S. support turns out to be fleeting, a tremendous change could be jeopardized. For the first time, the international community unanimously stated that if the lives of individuals, especially women, improve socially, economically and politically, then their health and reproductive choices would also improve. The ICPD agreement, entitled "Programme of Action," insisted upon gender equality in education, jobs, health care, and society, and demanded the empowerment of women to make choices about their reproductive lives. It also said that economic and social development for both men and women should be part of a holistic approach to population problems.

The ICPD agreement "could not have been drafted at the previous two conferences," CSPH Dean Allan Rosenfield, M.D., told The New York Times. "There is much more on the empowerment of women. It's a breakthrough, for example, to say that medical treatment must be available where an unsafe abortion has gone wrong." In addition to Rosenfield and Freedman, director of the reproductive rights project within the Division of Population and Family Health, other CSPH faculty at the conference were Stephen Isaacs, J.D., Nahid Toubia, M.D., and Angela Kamara, M.P.H.

Rosenfield sounded the alarm, however, about the new Congress and its policies on foreign aid, health care and abortion. "With Jesse Helms (R-S.C.) as chairman of the Senate Foreign Affairs Committee and Congressman Chris Smith (R-N.J.) responsible for review of USAID's population account in the House," said Rosenfield, "all the positive feelings that we had coming out of the conference are now being thwarted by the results of the elections of November, 1994."

Bella Abzug, former U.S. Congresswoman and co-chair of the group Women Watching ICPD, agreed. "The United States took a leadership role at the conference and committed to expanding support for USAID beyond family planning to girls' education and women's status generally," she told the Chronicle. "Not only is that additional commitment under attack in Congress, but some people want to get rid of USAID entirely." USAID is the U.S.'s principal vehicle for non-military foreign aid.

Although the $6 billion USAID budget is less than half of a percent of the federal budget, its destruction could have a seriously negative impact on the ICPD's ambitious agenda. According to the Programme of Action, the goal of family planning is "access to the widest possible range of safe and effective family planning methods." The document called for all governments to "remove unnecessary legal, medical, and regulatory barriers to family planning information, services, and methods."

More than family planning: A reproductive health agenda

Currently, approximately 50 percent of women or their partners in developing countries use effective forms of contraception--a dramatic increase in the last 20 years. Still, millions of women who want no more children have no access to contraception. Ideally, such family planning programs do more than help women and couples avoid unwanted pregnancies, Rosenfield said. They allow them to plan the births and spacing of children, which in turn helps to improve the health of both women and their children.

But it's difficult to get very far in international discussions of contraception without running into the issue of abortion. In some societies, Rosenfield explained, inequality between the sexes prevents women from making important decisions regarding reproduction without their husbands' permission. "Many women fear harassment and even violence as a result of such decisions," he said. "Consequently, some women carry unwanted pregnancies to term. Others desperately seek abortions, which continue to be performed illegally and under unsanitary and dangerous conditions in many countries. Botched abortions account for as much as 25 percent of maternal mortality--80,000 to 100,000 deaths--worldwide each year. And, for every one of these deaths, how many women are seriously injured?"

It was such a discussion of abortion that galvanized international media attention, particularly when the Vatican enlisted several fundamentalist Islamic states to help fight the position on abortion in the ICPD program. A Wall Street Journal editorial called the ICPD position "a vision of human relations that billions of human beings regard as morally and culturally offensive." In fact, the ICPD did not take an extreme position. Its one paragraph on abortion stated that women in all countries should have access to medical attention in the event of complications from abortion, whether legal or illegal. Furthermore, the Programme of Action said, "Prevention of unwanted pregnancy should be given the highest priority and all attempts should be made to eliminate the need for [abortions]." The document also stated that when abortion is legal it should be safe.

There is currently no common ground between those who support a woman's right to abortion and those who consider life as beginning at fertilization or implantation. The only possible common ground is to prevent unwanted pregnancy, which is what the conference concluded.

The conference went on to conclude that family planning is inextricably bound to women's general health, and women's reproductive health depends on access to information and good primary care. The Programme of Action noted that women are more likely to return to family planning and other reproductive health programs if they receive good primary care. The experiences of several developing countries, including Thailand, Taiwan and Nigeria, have shown that such programs work.

Finally, prevention of the spread of STDs and HIV/AIDS must be an integral part of the family planning effort. "One gets pregnant or is exposed to an STD through the same activity," Rosenfield said, "and separate programming--as though this biologic fact does not exist--does not make any sense."

The key to women's health: Empowerment and human rights

Having started down the humanistic path, the ICPD did not balk at the next logical step: women's empowerment.

The Programme of Action states, "Improving the status of women also enhances their decision-making capacity, especially in the area of sexuality and reproduction." Better education and jobs allow women greater economic and social choices. Improved status, in turn, creates the opportunity for women to play a critical role in the making of health care policy. Ideally, this translates into the ability to make a number of choices, including when to marry, when to begin childbearing, and how many children are appropriate.

As Freedman noted: "Realizing your ability to make decisions about reproduction means nothing unless you have the means to implement your decisions." Freedman and Isaacs said that women need power not only to implement reproductive health decisions, but to exercise their health care rights and human rights. Isaacs was on the planning committee for the NGO Forum.

These inextricable connections among population issues, women's health and women's rights brought the Cairo discussion to human rights. To the women's rights community, family planning and reproductive health care services are considered a means to advance their agenda, said Freedman, who conducted workshops on women's rights at the conference. Isaacs also said that human rights organizations are expanding their mission to include women's rights and reproductive rights. In March, Amnesty International published a booklet entitled It's About Time! Human Rights Are Women's Rights.

But some areas of reproductive health, such as abortion, do not yet fit into the political definition of human rights. "Some actions are obvious human rights violations," Isaacs said. "If you hold somebody down and sterilize them, that's a pretty clear violation. If a country bans contraception, philosophically it follows that it's the same. When it comes to access to abortion, I would make the argument that it's a fundamental human right, but politically we're just not there."

Although there are many battles to be fought, at the Cairo conference 179 countries did reach a breathtaking global consensus: Empower women so that they, and not government programs, can direct their health care. Then the world's health problems can be approached with effective human solutions. As with all such conferences, the question now becomes one of action. As of this writing, the Clinton administration seems to have decided to fight the Congressional trend toward international isolationism. The U.S.'s future role in family planning and international women's health remains to be seen.