RH Reality Check is saddened by the death of Rupert Walder. We just learned of his death today, and join his many friends around the world in mourning. Rupert wrote this piece for us last week and has been writing about Europe for us as part of our Global Perspectives series. You can read more about Rupert Walder in this tribute to him.
On April 16, just under 200 parliamentarians from 47 European countries debated access to abortion in Europe, and then voted on a report calling for safe and legal access to abortion in 47 Member States of the Council of Europe.
As reported throughout Europe and the rest of the world, a modified version of the original report was adopted by the Parliamentary Assembly of the Council of Europe with 102 votes in favour, 69 against, and 14 abstentions. While this vote is not legally binding for any of the Council of Europe countries, it did - and does - represent an important first adoption by any official pan-European institution of a report which calls on European countries to decriminalise abortion where it remains illegal, guarantee women's right to abortion, and also ensure that women and men have access to contraception at a reasonable cost.
The French Family Planning Association described the vote as "a major victory for all women in Europe, especially those [women] in Ireland, Poland, Malta and elsewhere, who have been fighting for recognition of this basic right." In Ireland, the Family Planning Association said the report "provides strong evidence of the level of consensus reached across Europe on the issue of abortion." By contrast, one Irish pro-life group described the report as "jaded and grossly out if touch."
During the four hour Assembly debate, which included 72 proposed amendments to the report text, many opinions were aired. According to The European Parliamentary Forum On Population And Development, it was not just personal opinions that drove some parliamentarians to vote against the report. Apparently, the original wording of the report was too progressive for some, with too much emphasis on human rights and not enough on prevention. Voting records in The Assembly are also made public, which would have made it difficult for some to openly vote in favor of a report which might contradict legislation and parliamentary opinion at national levels. And, while some parliamentarians may support access to safe and legal abortion, they may also feel the issue is a matter for national governments rather than a pan-European institution. (Interestingly, many Eastern European parliamentarians did vote in favor of the report, indicating that Eastern Europe - which is targeted vigorously by pro-life groups seeking to create alliances within these countries - is not such a soft option or breeding ground for the pro-life message.)
The lack of actual legal enforcement of this report may be a blow to some. But for others, the actual debate and vote represents an important indication that Europe is pro-choice. A spokesperson at the IPPF European Network says "We believe that this has been an important achievement...for Europe's policy on abortion as well as for the recognition of the right to access safe and legal abortion in [a] broad human rights agenda."
Proposed amendments to the report to incorporate conscientious objection for medical practitioners, the rights of the unborn child, and the rights of fathers were rejected. This is good news for the pro-choice movement in Europe. As Swedish Social Democrat Member of Parliament Carina Hagg put it during the debate: "We are in the hemicycle of the Council Of Europe, not in a church. This [debate] is not about our beliefs. We must make decisions based on fact and on what we read in international documents."
My feeling is that European parliamentarians continue to pick and choose European decisions that are acceptable back in their respective countries - which indicates that there is still much scope for national pro- (and anti-) choice activism at national levels across Europe.
In the end of the day, the adoption of this report is part of a process - of discussion, of engagement of activists with parliamentarians, of European agreement (and compromise), and also parliamentary and political accountability. As Ann Furedi from BPAS puts it; "Women's needs are the same in every society. Any national law that doesn't provide for easy access to legal abortion is a failure in that regard. But ultimately and importantly it remains for the citizens of each nation to decide how they wish their politicians to deal with this issue [of abortion legislation]."
In other words, if you are pro-choice, make sure you let your let parliamentarians and other policy brokers know about it. That is the only way European - and any other - country will remain or become pro-choice. Another will be to heed Carina Hagg's words and listen to the facts: where abortion is prohibited, as it still is in a number of European countries, women will travel or resort to illegal services to terminate their unwanted pregnancies.
]]>And the news is not so good. Fewer than a quarter of 68 priority countries are on track to reach the Millennium Development Goals (MDGs) on maternal and child mortality (MDG 4 seeks to reduce the morality rates in children under the age of five by two thirds. MDG 5 calls for a reduction of maternal mortality ratios by three quarters 75%). And while some countries, notably China, have made significant progress, many more - mostly in sub-Saharan Africa - have seen no progress or even reversals of progress.
Fifty eight of these 68 priority countries have high maternal mortality rates (MMRs). In Sierra Leone, the MMR is 2,100 per 100,000 live births. In Afghanistan and Niger it is 1,800. (By contrast, the MMR in Canada is 7, and in the UK 8.) In Chad the infant mortality rate is 209 deaths of children under the age of five per 100,000 live births. In Equatorial Guinea it is 206, in Cameroon it is 149. In 54 of the 68 countries there are fewer than 2.5 health care professionals for every 1,000 people. Which is "too few to make a difference," say the report authors.
However, experts who launched the report in London this week refused to be overwhelmed by the scale of improvements needed, and argued that one of the many agendas that need to be addressed is the very provision and dissemination of the data in the report so that policy makers can assess the scale of the problem. They do believe that many countries can achieve progress if there is more political will, more collaboration between donors and recipient countries, and increases in funding. They also point to the success stories of Tanzania and Bangladesh, poor countries where vast improvements in maternal and child health have been achieved over the last 10 years.
Ann Starrs, President of Family Care International, says essential future actions must include the strengthening of national and local health systems, dramatic increases in resources, and aid must be less volatile and better targeted to countries most in need. Or as Jennifer Byrce from Johns Hopkins put it, "We want big projects. Yes we need more money, but compared to spending on, for example, defense, the actual amounts needed are not huge."
And the reproductive health reality check on this agenda? In an editorial in The Lancet, Richard Horton writes, "Reproductive health, too often forgotten as an essential component of maternal, newborn, and child health strategies, requires immediate attention."
The Countdown report will be launched again in Cape Town at a Countdown Conference on April 17. The Countdown Conference takes place at the same time as the 118th Assembly of the Inter-Parliamentary Union, and also before the G8 Summit in Tokyo in July. Flavia Bustreo, who is facilitating the Countdown Conference, says this is a vital opportunity to engage with parliamentarians from around the world. "There is an urgent need to mobilize Members of Parliament in these 68 countries as well as in donor nations. As elected leaders they should represent the voices of women and children and protect their rights. Getting their commitment to do so is the objective of the Countdown Conference. Parliamentarians can lead the change for women and children."
The Countdown report is essential reading for anyone involved in health development. And the agenda to engage with parliamentarians with the report findings - rather than vague demands and complaints, and out of date information - makes perfect sense. What I do worry about is that any discussions with parliamentarians about reproductive and sexual health in this context will be side-lined. And any promises and commitments to maternal and child health will neatly avoid any commitment to provision of reproductive health services, including access to abortion, access to decent sex education, and access to contraceptives for all those people who need them. (Prevention of unintended pregnancies can apparently reduce maternal mortality by a third.) Whether or not politicians are prepared to make that leap of faith in discussions about maternal and child health remains to be seen.
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At the conference, Dr. Francisco Songane, Director of the World Health Organisation's Partnership For Maternal, Newborn and Child Health, put the challenge into real terms. He says an additional US $10 billion is needed if the MDGs on maternal and child health are to be met by the target date of 2015. Official figures for 2005 indicate that 536,000 women die in childbirth every year, although unofficial estimates suggest this figure may be as high as 872,000. MDG 5 seeks to reduce the level of maternal mortality by 75% by 2015, but has - according to Women And Children First - made the least progress of all MDGs.
Ros Davies, Chief Executive of Women And Children First, says, "Everyone must act now if we have any hope of meeting the target. We know what needs to be done. We need more health clinics and equipment, trained workers to deliver babies, safe abortion, and full access to contraception - and all communities should be demanding these."
UNFPA has a nicely articulated chart indicating where and when and how reproductive health contributes positively to all eight MDGs. But the fact remains that reproductive health - in all its facets and disciplines and agendas - is not a strong theme in any or all of the MDGs. And while the MDGs remain, for good or bad, a primary international development agenda at least until 2015, that means a continuing compromise for reproductive health in international development.
Barbara Crossette provides one explanation for the lack of reproductive health in the MDGs, a compelling if rather depressing analysis of the hows and whys and wheres of how things get done at UN and government levels. She quotes the then IPPF Director General Steve Sinding describing the MDGs as "dead letters" if the commitments of the International Conference On Population And Development (ICPD) in 1994 were not specifically upheld in them.
Women And Children First is arranging a further meeting in April to discuss future strategies for UK-based NGOs and their work in promoting reproductive health in the MDGs agenda. The general consensus from the first meeting in March is that work is needed to establish which reproductive health organizations are doing what in terms of advocacy and the MDGs. This process should apparently increase awareness of existing expertise and experience, and hopefully ensure future collaborations are optimally effective. This is a laudable and much needed strategy, especially as we hit the half way mark of the MDGs agenda. (2000 to 2015 is the life span of the ambitious MDG targets and expectations.)
But optimum effectiveness will not be achieved by a rethink of what has already failed to attract the attention of parliamentarians and policy makers and the United Nations decision brokers for the last quarter of a decade since ICPD. Optimum effectiveness will be achieved if and when reproductive health is high on policy agendas before declarations are written, and before goals are decided, and before proposals are put to invariably compromised and compromising United Nations bodies and their pay masters. The continuing trouble with reproductive health within the development agenda is that it is always an after thought, an uphill struggle against a trenchant fait accompli, something to loudly complain about after the event rather than strategically integrate at inception.
The MDGs will come, and go. They will be replaced by some other structures and goals after 2015. Time to think longer term if reproductive health and rights are to become truly integrated into the international development agenda. We may not, as individuals or organizations AND politicians, benefit directly from this long term agenda. But some of those many many thousands of women whose lives and families are so severely threatened by a lack of comprehensive reproductive health services will benefit if we get it right. And that is exactly what development should be about.
]]>This from a spokesperson at the International Planned Parenthood Federation's Central Office in London:
"PEPFAR's impact on the policy or programs of other donors is difficult to ascertain. There were very real concerns that other donors might downscale their efforts or pull out of countries in receipt of PEPFAR funding, which many feared would severely undermine the response to HIV and AIDS because of PEPFAR's dangerous ideological restrictions on working in critical areas or with certain groups and individuals. If anything, what has happened is that more progressive donors, including European donors, have changed their focus in PEPFAR countries and are concentrating their efforts on areas, particularly in HIV prevention, where PEPFAR has put serious limitations on the use of funds for evidence based programming, e.g. needle exchange, comprehensive HIV prevention including condoms, working with vulnerable groups such as sex workers or injecting drug users. These donors had always worked in these areas and have just increased their work, almost as a counter-balance to the in-built gaps in PEPFAR.
"The inherent danger is that if donor harmonization does not happen at country level, creating parallel systems, as PEPFAR does, severely undermines efforts to maintain a comprehensive approach to HIV programming. Due to the sheer level of money being committed at country level by PEPFAR it has managed to influence country level decisions on how to use HIV funds in spite of other donors."
Neil Datta, who runs the European Parliamentary Forum On Population and Development in Brussels, takes a harder line:
"PEPFAR has very little if any impact in Europe - it is people in developing countries who will suffer. European donors are all moving in a direction of harmonizing their aid in accordance with internationally agreed principles, such as the Paris Declaration on Aid Effectiveness, where aid should be based on these five principles:
1. OWNERSHIP: Developing countries will exercise effective leadership over their development policies and strategies, and will coordinate development actions;
2. ALIGNMENT: Donor countries will base their overall support on recipient countries' national development strategies, institutions, and procedures;
3. HARMONIZATION: Donor countries will work so that their actions are more harmonized, transparent, and collectively effective;
4. MANAGING FOR RESULTS: All countries will manage resources and improve decision-making for results; and,
5. MUTUAL ACCOUNTABILITY: Donor and developing countries pledge that they will be mutually accountable for development results.
"The abstinence-only earmarked funding in PEPFAR goes against modern principles of effective aid. The developing countries have not asked for American abstinence funding, abstinence-only approaches have no effect in the developing world where a significant percentage (in some cases up to one third) of sexual initiation among young girls is coerced or forced and abstinence-only approaches are in themselves disempowering of vulnerable groups, thus undermining other donors' efforts. Finally, the earmarked funding for abstinence-only programs casts in a negative light the otherwise noble and important efforts of PEPFAR, for example, in making a significant contribution to malaria eradication and providing HIV/AIDS treatment."
Chris McCafferty MP, and Chair of The UK All Party Parliamentary Group on Population, Reproductive Health And Development, describes PEPFAR as giving HIV and AIDS organizations two choices.
"They can either continue the work they are doing which they know is right and working. Or they can take the [PEPFAR] funding and not do that work. The regulations that PEPFAR imposes on recipients of its funds inhibits a fair assessment of what relevant organizations are achieving, and is detrimental to existing evidence based programs and projects."
Health systems expert David Daniels, who is a Director at YozuMannion Ltd, argues: "[Donors] have a duty to maintain their promise and commitment to providing ARVs. We have to continue doing that. But if you don't support preventive work, the conclusion is obvious. The spread of HIV and AIDS will increase, especially within the poorest communities around the globe. Yes we need lots of money to tackle HIV and AIDS, but that money can't be restrictive and ignore prevention."
Steve Cockburn, Co-ordinator of the STOP AIDS Campaign, the campaigning arm of the UK Consortium On AIDS & International Development, picks up on the actual amounts of money being talked about. "If Congress does agree to an increase to 50 billion for PEPFAR, and that money is delivered correctly then it would be a dramatic contribution. But the fairly unanimous feeling amongst HIV and AIDS organization in the UK is that current PEPFAR funds are - to an extent - being wasted. There is evidence at country level that PEPFAR funding is having a detrimental effect in its current prohibitive state."
The USA remains an important international donor, if nothing else for the sheer scale of its contributions. However, the strategies that currently guide the US's contribution through PEPFAR remain more political than practical, and more prescriptive than empowering. PEPFAR was and remains an opportunity for vital interventions. In its current state that intervention is severely compromised.
See all of RH Reality Check's extensive PEPFAR coverage.
]]>Or perhaps I should buy it -- as a deliberate and calculated attempt by the anti-abortion lobby to be seen to be representing the previously, seemingly, unrepresented. They have, after all, often sought to be seen to be representing other "unrepresented" groups such as disabled people. Why not men?
According to one abortion counsellor here in the UK, men do sometimes feel uninvolved or ignored when it comes to their partner's experience of abortion. "It may be very upsetting for men," says the counsellor. "But the priority for men and their partner's abortion is for them to be supportive, to be seen to be being supportive at what can be a difficult time for a couple." As for the later, down the line suffering that men may feel, the counsellor admits that she does not see any men for post abortion counselling. "If men are suffering, it is probably more about their own problems than abortion," she says.
Ann Furedi of the British Pregnancy Advisory Service, the UK non-profit which sees over 55,000 women each year for abortion care and thousands more women and their partners for non-directive pregnancy counseling and information about their options, told me, "Men, like women, may have a variety of feelings about continuing or ending a pregnancy, and understandably, both partners may feel they wish they hadn't had to be faced with a complex pregnancy decision. But there's no typical reaction of men -- or of anyone else -- to abortion...We should shy away from attempts to make political capital out of such intensely personal situtations."
Because they are not involved, because it is not about them, because there is so much deliberate mystification and polarized politicization of abortion, I am sure there are many men who do not know how they should feel about a partner's abortion. There are also definitely some "concerned" groups who would like to give male post abortion syndrome legitimacy. Bring the two together, and you somehow have a body of proof about men and post abortion syndrome? I don't think so. (Men do like to be told how they should feel, I know. But there is guidance, and deliberate trickery.)
Why should the emphasis not be on men? Because it further mystifies and complicates the messages that are needed about abortion: confidentiality, access, the personal before the political, the woman's needs and expectations first. Men need to be more involved in their own and their partners' reproductive health and rights. But not like this. Not as the manipulated after-the-fact victims. They need to be at the time, and every time, enablers and supporters and partners.
At the Reclaiming Fatherhood conference in San Francisco last November, one of the speakers apparently quoted Eliot's Hollow Men ("Remember us - if at all - not as lost/violent souls, but only as the hollow men/the stuffed men.") The final line of the poem goes ‘Not with a bang but a whimper' - which is, I feel, exactly how the men and post abortion syndrome debate should proceed.
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At the end of 2006, musician Damian Montagu and filmmaker Christian Banfield took a spontaneous trip to Cape Verde. "We didn't really know what we were doing. We just both loved Caesaria Evora's music, and thought we could maybe meet up with local musicians," Damian explains.
On their first morning on the island of Mindelo, the two sat on their hotel veranda, not really believing that a spontaneous idea in a pub in London had actually got them to Cape Verde, and not really sure what to do next. As they drank their coffee and considered their options, a procession of school children and musicians danced by on the street below. It was December 1, and the procession was a World AIDS Day event.
"It was one of those moments," says Damian. "I looked at Christian, and we both realized that we should be working with those musicians, and letting them sing about HIV and AIDS." The resulting collaboration, as filmed by Christian, paints a haunting but beautiful picture of older and younger generations of Cape Verdeans realizing quite what an impact HIV and AIDS is making on their communities.
On World AIDS Day 2007, Damian returned to Cape Verde and submitted the film to the national and local media, all of whom were much taken by the high quality of the film and the strength of the message. "It involved local people who don't usually get access to decent recording and broadcast equipment," says Damian. "It was a collaboration, a real collaboration for me as a musician. But I do feel we gave something back, rather than just turning up, tuning up, playing and then disappearing back to London."
During his visit, Damian presented the film to the Mayor of Mindelo to an enthusiastic response. CVT, the Cape Verdean national television station, broadcast the film repeatedly during World AIDS Day, and also featured it in the main news show. Additionally the Cape Verdean national radio station broadcast the song and interviewed Damian about the project. The song has also now been circulated amongst the youth orientated radio stations and their DJs and is receiving strong support. And local health authorities are now integrating the film into their awareness programme for 2008. In addition a leading local doctor will now be incorporating the film into his HIV/AIDS awareness program.
The film was also presented to universities and schools across Mindelo and was shown to large groups of students. These screenings were followed by lectures from head teachers about the message of the film and the response from the children has resulted in the schools now incorporating the film into their teaching programs.
Before the December 2007 trip, Damian and Christian and DJ and music producer David Hill established World Awareness Recordings. The team is now working on an `African Sessions' project which wants to create further collaborations in other African countries including Mali, Senegal, and Ethiopia.
By his own admittance, Damian became an HIV and AIDS activist by chance.
"If you had asked me three years ago what I would be doing today, I would probably have told you I would be worrying about the music for the next Budweiser or Audi advertising campaign," says Damian. "But in Cape Verde, we started something that we want to continue. We had no idea what we were doing when we got there. But local musicians spoke to us, with their music and about their lives through that music."
World Awareness Recordings is looking for future partnerships with musicians, and anyone else interested in spreading empowering and resonant awareness about HIV and AIDS. Speaking to Damian and David, I get the distinct impression that they are a little surprised that they have ended up as HIV and AIDS activists. But this innocence and honesty gives them the space to be creative without preaching, and collaborative without being condescending - a refreshing approach which many an agency and organization would do well to take note of in their HIV and AIDS campaigns.
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Having just returned from Kenya, I would like to add my voice to Florence Machio's concern that the political unrest in that country has and does and will continue to seriously affect women in that country.
The chief nurse at Nairobi's Women's Hospital says that the number of rape survivors seeking treatment at the hospital doubled in the wake of violence, and that there were many many more women who were unable to seek treatment in inaccessible areas of the country, including the notorious slums of Nairobi.
While I entirely agree with Kenyan journalists that the international media were running around looking for ‘good' stories about the unrest without seeking to really understand the situation, I was also sorry to see quite how quickly that unrest was affecting the people of Kenya - and more specifically the poor and the displaced. (It is a humbling experience lending someone your mobile phone so they can call their family to see if they are safe and alive.)
The European Union has threatened to reduce aid to Kenya if a solution is not found over the disputed presidential elections. The US, UK and Canada are expected to announce their position in the next 24 hours. The US has already made some vague threat about not conducting "business as usual" until political harmony is found.
Business as usual in local terms would be a continuing decline in the Kenyan Government's spend on health, which has already dropped from US $10 per annum per person in the 1980s to US $3 today. Business as usual would also be a continuation of 42% female unemployment rate, 24% of women having no power in decision making within the family, and 16% of women agreeing that their husband is justified in beating them if they burn food.
While donors appear to be offering little to the process other than threats to close their purses, one wonders when the real people of Kenya will have their concerns and needs addressed. (And if we really believe our own mantra, those needs must include sexual and reproductive health and rights and eradication of gender-based discrimination and violence.) The donors? One representative of a huge multilateral donor told me, "The results of the elections won't make much difference. We will just need to make sure our projects are managed by whoever ends up in power." Business - including the business of development aid - as usual I guess. There, but not there for those who are not in the political ascendancy.
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Whatever the messages should be in 2008, they need to be disseminated more broadly, not just to the converted. The dialogue started at the Women Deliver conference in October with NGOs not directly involved in SRH, and with policy brokers who came to the conference, needs to continue. But more importantly, a dialogue with those who did not attend the conference needs to commence. (A parliamentarian or civil servant who does not know about sexual and reproductive health is as useful as one who opposes it.) This also goes for the world's media who stayed away from the conference in their thousands.
In terms of means of messaging, according to Google, we need to be creating social networks, encouraging our supporters to get more involved online, using available technology to create worldwide networks. In my experience, the majority of politicians and civil servants have only just figured out email, and remain most interested in article and stories that are written in hardcopy editions of newspapers. Let's not loose supporters before we have found them - naturally not ignoring technological advances as they become suited to our needs. (This lack of compatible means of communication remains a problem for anyone engaged in multi-country campaigns. Maybe Bill Gates had a point about everyone needing a computer.)
And the actual messages need to have a more resonant focus. (One of the problems with the recent launch of a Humanitarian Appeal by UNFPA and others is that it is asking anyone for anything for something as soon as possible.) Each and every SRH organisation has its own particular focus, its own targeted agenda, its own "unique selling proposition." Which may be deemed necessary, but it is confusing to the outsider. And other than the rather indecipherable and dry Cairo language, is there any real consensus on the language and the agendas that need to be discussed and promoted?
The SRH lobby also has a big problem when it comes to the messages of personal stories and testimonies. There are limits to how much we can expect the "victims" of a lack of access to services and drugs and information to tell their stories. Unless we are paying them, at which point their stories and experiences become institutional property and these people's real voices get lost in the desire to explain and promote those institutional unique selling propositions. And who - quite rightly - should be expected to publicly celebrate (on message) the emancipation of having had access to a safe and affordable abortion, or any other ultimately pretty personal experience? Making the political personal is a nice approach for the media. But individuals may not feel comfortable about having their experiences made into ammunition for media/public/political debate.
In the end of the day, despite the mercurial messaging, the agenda remains the same: SRH is woefully under-funded and compromised and misrepresented. Under-funded because we are not reaching the right people with the right messages. Compromised because SRH is just one of many other development and health agendas out there, and we have not sought sufficient association with those other agendas. And misrepresented because we constantly try and re-invent the wheel - and the message - in an effort to appear relevant.
You all knew all this already. It was just a festive reminder. Along with the fact that World AIDS Day is not just for Christmas.
]]>A new report from FORWARD suggests that 20,000 girls under the age of 15 are potentially at risk of FGM in England and Wales, and that the practice is on the rise in the UK. The study was designed to inform the planning of a comprehensive national strategy in the UK which will help to speed up efforts to end FGM within one generation.
Otoo-Oyortey explains:
"Here in the UK we do have good Government policy on FGM, but so far no-one has been prosecuted under the dictates of new legislation that came into force in 2004. [Two doctors have been found guilty of serious professional misconduct by the UK General Medical Council.] The problem is that so many different sectors - from social services, to health service providers and community-based organizations - need to work together to provide strategic interventions.
"In London, some councils are beginning to working together, but elsewhere around the UK there is no clear strategy for organizations working collaboratively to address FGM. So we have good policy and legislation, which is vital, but we need to work much more closely in the co-ordination of education and awareness-raising. If we don't reach local communities, we will not be able to address this issue effectively."
FORWARD is in its second year of a Young People Speak Out project, which has helped both young women and men to speak up about the need to eradicate FGM. These young people, mostly aged between 18 and 22, are promoting awareness amongst families, in schools and on university campuses, giving the eradication campaign a voice and legitimacy.
FORWARD is also part of a network of European countries (Belgium, France, Spain, Sweden, UK) seeking to learn from each other's experiences in order to create best models for interventions. In France, there is no specific legislation criminalizing FGM. However, using other legislation there have been successful prosecution of practitioners. In Sweden, there is a national eradication strategy closely aligned to the work of social services networks.
According to Otoo-Oyortey, there is anecdotal evidence that FGM is decreasing in Africa, but not enough hard data. "In Burkina Faso for example, there is a good system whereby perpetrators can be reported to the authorities but we don't have any evidence that the actual prevalence has dropped. We need hard data to inform our future strategies, in African and in Europe."
This lack of data - if frustrating - is not surprising. With criminalized status in many countries, those who perpetuate the practice of FGM go underground in order to avoid detection. It is also performed on very young women, many of whom are "protected" from the outside world by their families and communities.
There is also - I would argue - the problem that FGM remains a complicated agenda, one that poses some fundamental questions about the control of women's sexuality and health - easier to ignore than discuss, easier to leave alone than address.
And there is an argument that those who seek to eradicate FGM are dabbling with cultural practices and traditions. On this issue, Otoo-Oyortey is very clear. "Every culture has its strengths. FGM is not one of them, in any country."
]]>Writing about the recent Women Deliver and the Global Safe Abortion conferences in London, Beth Frederick concluded that we need to be on the lookout for policy makers who "forget or ignore" the relevant agendas. In terms of language, I think there is an important third here: don't understand.
It did strike me at Women Deliver that some participants - including detractors - were using a language that just doesn't mean very much to anyone other than the converted and the unconvertible. In our efforts to articulate the quiddity - the essence, the correctness, the validity - of our arguments, we are confusing policy makers and the media and other prospective supporters. If Cairo was about winning language, then the following few decades seem to have been about complicating that language. And to such an extent that any decent journalist or civil servant or policy broker has switched off before we have got to the end of our second sentence.
We all know the reasons why we use such ‘complex' language: to push the agenda onwards and upwards; because we really, really (really?) need to explain the technicalities of our work; to claim the moral high ground; to impress; to discredit our detractors; to differentiate ourselves from our competitors. And the agenda and therefore language is always evolving, with new contraceptive regimes and technology, new political conquests, all of which need to be "explained."
But somewhere along the way, those of us who are promoting discussion about sexual and reproductive health and rights (snappy, huh?) seem to have become so involved, so committed, to our particular agendas, that we have stopped speaking English - or Spanish or French or Russian. With some notable exceptions, most of the briefings and reports at Women Deliver read like short, incomprehensible novellas.
There is also the polarization of our language on issues such as abortion and sex education. How on earth can we say what we really need to say on these issues without first ensuring that we have made it so very clear that we don't think this, and don't advocate that? It is too defensive, too contextualized for the outside world.
And the all important voice of "youth" has also been so sanitized that youth advocates sound like nascent civil servants rather than real young people. Do any normal young people ever really used the term "peer education," or "youth advocate" or even "reproductive health?" I doubt it.
There is also the polarization of our language on issues such as abortion and sex education. How on earth can we say what we really need to say on these issues without first ensuring that we have made it so very clear that we don't think this, and don't advocate that? It is too defensive, too contextualized for the outside world.
Women Deliver demanded that we reach out to new audiences. Let's not do it with language based on programs of action, vital as these documents remain. Let's do it with real words (and also images) that have life and resonance beyond our own particular offices and corridors and conferences.
]]>Ministers of Health and Finance turned up. They made a powerful declaration of support, and concrete suggestions for how to improve the status of maternal health on the international development agenda. Reproductive and maternal health organizations and agencies used the conference to invite other sectors to comment on their work – sometimes critically. And a lot of questions were asked about why 20 years after its launch, the Safe Motherhood Initiative (SMI) is not meeting its targets.
Although these targets have not been met, attitudes have changed. Fred Sai, who chaired the 1987 Safe Motherhood Conference, dismisses any concept that maternal health is a local, cultural issue that should not be tampered with. “There is only one culture that we need to look at. The culture of delay that maintains the terrible difference between rates of maternal mortality in the North and in the South,” he says. A Nigerian conference delegate agrees with him. “We don’t have time to stop and theorize about cultural influences. We see the problem every day, in women’s homes, on their doorsteps. We just need to get on with it.”
Others brought further realism to the conference. On the final day of the conference, The Norwegian Government announced a new financial commitment to Millennium Development Goals 4 and 5, with the proviso that resources will only be awarded to those organizations that can prove their effectiveness at local levels. Mia Faikenberg, a Danish parliamentarian who attended the Women Deliver Ministers’ Forum, said she had enjoyed the “big passion” and the creativity at the conference. “As a parliamentarian a lot of people are asking me about increased funding. It is a good agenda. I understand why it needs to be supported. But I want to know how effectively our existing funding is being spent. The real money should only go to those who are doing the real work.” IPPF Secretary General Gill Greer agrees, "Today, no-one has an automatic right to funding. We need to prove we are making a difference.”
In Malawi, a huge difference has been made in the fight against maternal mortality, thanks - in no small part - to the determination and vision of its Minister of Health Marjorie Ngaunje. “In my country we have a Road Map to reduce maternal mortality that is fully integrated into the health SWAp,” she explains. “We want pregnancy to become a cause for celebration not a death sentence in Africa. We know what we want, and we are using the development aid structures to make it happen.”
The expectations were high for this conference, but the organizers were optimistic about the outcome. Executive Vice President of Family Care International (FCI) Ann Starrs says “Women Deliver has put maternal mortality on the global agenda in a way that it cannot be ignored.” FCI’s President Jill Sheffield agrees. “This conference got people really thinking about what women deliver to the world. It has articulated the place of women in the broad context of development. And it has opened the doors to new partners outside the health sector.” What does she expect at the 40th Anniversary of the Safe Motherhood Initiative? “We need to meet a lot sooner than then. We need to keep this agenda visible and strong.”
The UK Department For International Development pledged £100 million to UNFPA on the first morning of the conference. The Japanese Government sent a message to the conference announcing its intention to place global health at the centre of next year’s G8 summit in Japan. And The MacArthur Foundation pledged US $11 million to reducing maternal mortality in Nigeria and India.
On the first afternoon of the conference Sudanese midwife Awatif Altayib Mohamad Hussein addressed the plenary for three minutes. Awatif has travelled for up to 10 hours a day on a donkey to reach rural communities where women – as she did once – suffer from obstetric fistula. I asked her what her message to Women Deliver would be. “The US and others need to give more money so I can continue my work,” she says.
Whether or not Awatif gets more money for her work is beyond her control. It is not beyond the control of many others who attended Women Deliver. And to make the next 20 years a success rather than a further failure, some of the candour and pragmatism and good will shown at Women Deliver needs to be disseminated further afield – and the issues translated into a language that those who do not as yet understand the importance of the women deliver agenda will comprehend.
]]>Dilys Cossey, who was a member of the NGO coalition that lobbied for the original 1967 legislation, explains the context at that time. "We had an enormous amount of informed discussion thanks to the on-going social reform agenda at that time. It is interesting and encouraging that the 1967 Act has stood the test of time," she says. "None the less, we need to continue the debate and lobbying to make sure it is relevant to today's needs and expectations."
Ann Furedi, Chief Executive of BPAS, agrees the law has held up well, but with some qualifications. Furedi would like to review the current provision that two doctors' consent is required to allow a woman to have an abortion; entertain the possibility that qualified nurses should be allowed to perform certain abortion procedures; and bring Northern Irish abortion legislation and practice in line with the rest of the UK.
Speaking last week at a BPAS open meeting on the current legislation, attorney Barbara Hewson argued that any law should be as cost effective and efficient as possible, and also that other important medical procedures only required the consent of one doctor - two arguments against the existing requirement for two doctors' consent. Hewson agreed that there is need for more discussion as to whether or not nurses could provide abortions, especially within the context of new abortion procedures. And on Northern Ireland, Hewson said however politically sensitive it may be, there is a strong argument for the sake of uniformity for the Northern Irish law to be amended.
Other discussion at the meeting focussed on ethics committees of Primary Care Trusts effectively taking the law into their own hands by making arbitrary decisions about women's access to late abortion - partly thanks to pressure and legal test casing by pro-life groups, and the need for clear fact-based proposals to Parliament and civil servants, rather than opinionated demands.
The law currently provides a framework for access to abortion in the UK. It does not empower nurses and other qualified medical professionals other than doctors to increase access to safe and legal abortion. Nor does it provide for the needs of women in Northern Ireland. This fortieth anniversary provides an opportunity for reflection, and also an arena for positive change.
]]>"It is a pity that reproductive health is not explicitly mentioned as a prime target [in the IHP]," says Tony Worthington, a Minister in the Blair Government and a leading member of the Government's Select Committee on International Development. "Coordination is important, but so is courage. The lack of courage in putting reproductive health at the center of the Millennium Development Goals has lessened the fight against infant and maternal deaths and deepened poverty."
Worthington, who is now Chair of the Safe Hands For Motherhood NGO, argues that good reproductive health - including action to prevent HIV/AIDS - is the central building block of good health. "We have not said that because others are afraid of the truth and it has cost the poor dearly. This new partnership should start by returning to another international health partnership, the pledges of the Cairo Conference in 1994 and honoring them. We would then see that this IHP is not just words," he says.
The International Planned Parenthood Federation agrees that health systems do need to be strengthened and that there is an urgent need for greater harmonization by donor agencies. However, IPPF also believes a focus on all aspects of maternal health, including sexual and reproductive health and rights, is vital if the Millennium Development Goals are to be reached, and remains concerned that there is only one mention of reproductive health in the IHP agreement.
"We are concerned that areas of public health that are considered controversial in some countries, such as unsafe abortion, will be neglected unless sufficient focus is placed upon these issues by donor agencies and recipient countries. Likewise, we remain concerned that the role of civil society in the IHP has and continues to be at the margins of the negotiations and discussions," said an IPPF spokesperson.
"In terms of support to reproductive health, show me the plans with these [reproductive health] issues well articulated and linked to nationally agreed Mid Term Expenditure Frameworks and comprehensive monitoring and evaluation frameworks both targeting the poor - then I will think this new IHP will effect change," says one international health systems expert.
These three perspectives from a politician, the world's largest reproductive health NGO, and a health systems expert suggest it will be a hard struggle to promote reproductive health in the IHP. Another missed opportunity? Or perhaps an oversight, which could be redressed with some hard lobbying as the IHP rolls forwards?
]]>And more research from the family planning association in the UK for Sexual Health Week (August 6-12) showed that only 39% of people say talking about condoms with a new sexual partner is an easy conversation to have. Of those who said they did not find it easy, 70% of people said they found the conversation embarrassing and 42% said it's a turn off. Thirty-six percent said it is such a tough conversation it makes them less likely to use a condom.
How about the rest of Western Europe? All safe and practicing safer sex? Not according to the Durex Global Sex Survey which indicates that seven of the top 10 countries where unprotected sex is most likely to occur are in Western Europe - Norway, Greece, Sweden, Finland, Denmark, Ireland and Iceland.
In Denmark, Sex & Samfund are launching a "Remember The Condom" campaign in September in collaboration with the Danish Ministry Of Health. "The two real problems are that young people are more worried about pregnancy than STIs, and public investment in good STI prevention programs has declined," says Sex & Samfund Executive Director Bjarne Christesen. "We are hoping our campaign will do what it is called, and remind people they need to protect themselves."
Dortje Braeken, Senior Adviser For Adolescents And Youth at the IPPF, worries that in countries such as Sweden and Finland where there is a very open attitude to sexuality, promotion of condom use is still with messages just about avoiding disease and pregnancy. "We definitely have condom fatigue in Europe," she says. "And that is partly thanks to the way condoms are promoted. Look at the leaflets in condom packets. They are too dull and clinical. They need to create some links between condoms and sex, not just condoms and disease or pregnancy."
Whether it is a reminder or a re-think that is needed, the facts from Durex do suggest that there is more to promoting safer sexual health than the liberal attitudes to sex and sexuality found in countries such as Sweden and Denmark and Finland. These attitudes need to be translated into promotional messages that actually mean something to individuals who are having sex.
]]>Reproductive health advocates and activists still have a long way to go towards getting European governments to commit sufficient funding to - as well as discussing the theoretical merits of - SRHR programs and projects. From a distance, European parliaments may appear a haven of liberal support for SRHR compared to Washington. But they - like their North American counterparts - must be judged on their actual performance as well as the relative erudition of their debate on sexual and reproductive health and individual rights. Parliaments debate. Governments act on that debate, depending on how important they feel the debate has been to national, regional and international political and economic priorities. Assistance to sexual and reproductive health remains a low political priority throughout Europe.
Only six European donors have reached the UN target of allocating their GNP to development aid. European donors only account for 40% of aid to population and sexual and reproductive health activities. And while many European countries do continue to increase their contributions to population and reproductive health activities, this increase is slow. There is still a shortfall of approximately 61% from external donors for the International Conference on Population and Development (ICPD) agenda in the developing world.
"Policy support from European governments since [the ICPD in] Cairo has been very strong. What is less obvious is the provision of actual resources," says David Daniels, an expert in health systems and director of health care consultancy YozuMannion Ltd. "In Europe," he argues, "there is an important defense of language and policy, but less actual money being allocated for genuine sexual and reproductive health programs."
So while support to SRHR programs and projects in the developing world may remain an interesting point of debate in European parliaments, it is not an economic priority by any means for most European governments. (Indeed, I also believe that trends towards sector-wide support to developing world countries actually provides some European donors with a outlet mechanism for exactly how their development aid money gets spent at all.)
Which leaves us pretty much all in the same boat with a lack of sufficient funding for that - fairly straightforward and fundamentally not very expensive - Program of Action developed in Cairo.
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