The origins of the word mother are said to be the Latin mater, meaning source or substance, and mamma, meaning breast. It was only in 1863 that the use of "mother" meaning "to take care of" became common. Motherhood has many meanings across cultures and many of these meanings have changed over time.
For many, the most familiar and enduring meanings of motherhood are those commonly associated with caring, relating, intimacy and emotional needs. Particular human relations in the family, friendship as well as sympathy and concern for others have traditionally been neglected and excluded in the field of ethics and moral philosophy.
When the experience of women began to be brought into the domain of moral consciousness, feminist philosopher Virginia Held noted that what emerged as the most fundamental and central social relation was the relationship between the mother or mothering person and the child. Yet even as many cultures accord motherhood and what they consider "motherly" roles with a great deal of reverence and respect, the same roles also oftentimes overlap as a site of subordination and devaluation for both women and girls.
Feminists are credited with pointing out the way in which the acceptance of the domestic ideal is the foundation of women's oppression. While some radical feminist positions (popularized by media) did, early in the women's movements, portray the choice of motherhood as "false consciousness," it is hardly fair to say that women cannot freely choose to be mothers and take on primarily domestic roles in the family without ending up oppressed. The point about linking motherhood and women's oppression is perhaps best understood in the context of the enforced ideal, role and state of motherhood.
In many societies, to this day, becoming a wife and mother continues to be the only option for women and girls. As a matter of survival, often compounded by societies' claims of cultural and religious identity, women and young girls are pressured and become mothers. In such situations, choice is simply not an issue.
We don't even have to make a comparison from our great-grandmother's generation, to imagine how this works -- because it's still happening today.
The Texas sect practicing polygamy in violation of US laws, was also discovered to be marrying off girls aged 14-17 to much older men with several wives. Warren Jeffs, the reputed leader of the Fundamental Church of Jesus Christ of Latter Day Saints (FLDS), who has been charged by the authorities in Arizona with conspiring to commit sexual conduct with a minor, himself had 70 wives.
In the sect, marriage and submission to one's husband (in a polygamous marriage) was the only future for a woman since the sect believed that men had to have at least three wives in order to "reach the highest degree of glory in heaven." One of Jeff's former wives recounted her life in the sect, as a young girl forced to marry a man with several wives, and how after running away, she faced a custody battle over her children. As alarming as the story was to the public, it was painful to witness how the children were hauled off and taken into custody by the police and now continue to be separated from their mothers. Easily, the moral hysteria around polygamy tends to focus on the "unusual" sexual arrangement without necessarily taking issue with the lack of women's agency and freedom in such arrangements. Indeed, the issue of polygamy is a complex issue, one which is usually complicated by cultural difference. But as we bore witness to the fumbling state, ill-equipped to handle the complex issues of individual women's and children's rights clashing with "religious group rights," many were left wondering about the future of the children who were placed in foster care. But how about the wives and mothers left behind? Admittedly, a case like this presents no easy solutions or answers.
On the other hand, FLDS's practices (which included controlling women's and girls' mobility and access to information) are certainly not a unique feature of one cult. All over the world, major religions led by its male religious authorities still actively work to limit women's and girl's access to information, particularly when it comes to sexuality. Conservative opposition to sexuality education in the US for instance, is not just a matter of religious preference but the very stuff of politics. Similarly, politicians in Manila in the Philippines have gone as far as banning modern family planning methods simply by virtue of their own religious beliefs on the matter.
Within many religious traditions, considering motherhood as a choice and a woman's decision remains a big challenge. According to Lynn Freedman, the threat that the International Conference on Population and Development (ICPD) posed for religious fundamentalists was not really fertility regulation itself but the challenge to traditional patriarchal social structures.
Their fear really isn't so much that feminism or women's human rights will suddenly lead all women to reject motherhood but rather that in the capacity for choice, women are challenging the very notions that rationalize male domination embedded in traditional meanings of motherhood.
]]>"Multilateral consensus continues to be in crisis because it is still subordinated to the decisions of a few; whereas the world's problems call for interventions in the form of collective action...International rules must be binding."
He received accolades for his skilled use of diplomacy as he tackled the thorny issues of the Iraq war, immigration and religious diversity, but when he met with some of the victims of clergy sexual abuse, he got mixed reviews. Some said they were impressed that he actually met with some of the victims, while others said he really didn't do much because it was all talk and no action.
Saying that he was "deeply ashamed" at the breakdown in US values, the Pontiff acknowledged at last that the situation was "sometimes very badly handled."
Peter Isely, a National Board member of Survivors Network of those Abused by Priests (SNAP) and himself a victim of clergy sexual abuse, demanded a clear course of action from the Vatican, namely the amendment of canon law to ensure that every priest who has assaulted a child anywhere in the world will be removed from ministry and disciplinary action against any bishop who has been involved in covering up an assault.
David Clohessy, another victim and member of the network added: "If the pope would clearly, publicly and severely discipline even a handful of complicit bishops, bishops who knew or suspected abuse and ignored it or concealed it, that's the easiest and most effective step."
A Pope able to talk about "human rights" on the level of global community and responsibility on one hand but only able to acknowledge the pain, harm and suffering by victims of the clergy's sexual abuse with "sense of shame," shouldn't be surprising. For years, the Catholic Church has been dealing with debates regarding social teaching and indeed, a number of the issues consistently coming to fore have been about sexuality and human rights.
When the Pope invoked "human rights" as a collective responsibility among nations, his position reflected one of many changes in the ways we now think about human rights. By no longer drawing a division between the civil and political on one hand and economic, social and cultural on the other, he went outside the traditional understanding of rights that confines it to a relationship exclusively between the state and its legal citizens. But while the Pope can speak on behalf of "the marginalized" in addressing the world's most powerful nation with ease, how is it that he is unable to take action on members of the clergy who both perpetrated sexual abuse and concealed it?
The answer isn't simple (and I don't want to oversimplify it) but neither is it rocket science. A huge part of it is sex -- that all sex (outside marriage and procreation) is sin. From a human rights perspective, what usually matters in a case like sexual abuse is the violation of the person; in this case, many victims were children when they underwent the ordeal.
He said that: "It is a great suffering for the church in the United States and for the church in general and for me personally that this could happen. It is difficult for me to understand how it was possible that priests betray in this way their mission."
While the Church is able to acknowledge the harm that was inflicted, it isn't always clear what it imagines that harm is. Is it pedophilia or the violation of priestly vows of celibacy? Is it the mishandling of cases by American Bishops?
For the victims, this means that their own sense of justice still plays no part in the Catholic Church's policy on sexual abuse. Anne Barrett Doyle co-director of Bishop Accountability, a Web site that documents the sexual abuse scandal, astutely pointed out that:
"Rather than shifting attention to pedophile priests, he needs to focus on the culpability of bishops. The crisis occurred because many U.S. bishops were willing to hide their priests' crimes from the police with lies."
With a very limited and negative view of sexuality, the Catholic Church's attention always seems inordinately focused on what it views as "unnatural sex acts" that it doesn't bother distinguishing between consensual acts and abuse. But Papal policy of "keeping pedophiles out of the ministry," has not meant justice for those who were abused by priests. Instead it has meant banning "homosexuals" from the church. Within the first five months of his reign, Pope Benedict made it clear that his position is based on the church's position issued in 1961 which equates homosexuality with pederasty.
Moreover, exclusion doesn't only happen on the basis of sexual orientation or non-conforming gender behaviors. Clearly, even married people can "sin" in sex when they use modern family planning methods. Rosemary Radford Ruether, a feminist theologian recalls how the 1968 affirmation of teaching against modern contraception in the Humanae Vitae was rejected by over 600 theologians when the encyclical was adopted.
Sadly the Pope's inclusive message of human rights and community in the context of geopolitical inequality gets lost when its archaic views on sexuality makes it very clear that there are groups of people who remain excluded.
]]>Getting to the heart of the matter, a series of forums organized at the Faculty of Law at the University of Toronto from April 1-2, 2008, offered an opportunity to tackle the core of the conundrum: sex and our ways of viewing sexuality. Oishik Sircar, Women's Rights Fellow of the International Sexual and Reproductive Health Program of the Faculty of Law and lead organizer of the forum aptly entitled, "Confusing Conflations," invited the participants to explore the issues of sex and trafficking and how, despite their constant overlap and connection, they are hardly identical issues.
The first day included a screening of "Tales of the Night Fairies," by acclaimed Director, Shohini Ghosh. The film featured women from the DMSC (Durbar Mahila Samanyay Committee or the Durbar Women's Collaborative Committee), that stemmed from The Shonagachi HIV/AIDS Intervention Project (SHIP). By featuring the lives of women in sex work, the feature grapples with the complex issues around consent, agency and exploitation in prostitution. On their own terms and in their own voice, the real women (and one male sex worker) featured in the film challenge the usual "images" of prostitutes (especially women) as one-dimensional characters, helpless victims in need of "rescue."
Prof. Kamala Kempadoo, of York University Toronto, pointed out how there are now a myriad of recognized views about sex and sexuality that challenge the traditional binary of "good" and "bad" sex so that the "acceptability" of sexual relations is no longer solely framed as an issue of whether it happens within or outside marital relations.
In the case of prostitution, one position which has gained prominence is the struggle for the recognition of "sex workers' rights." Coining the position of collectives of sex workers as "rights" has led to profound interrogations of the subject of rights, women as well as specific classes of women, having for a long time been excluded from the realm of rights claiming.
Yet Prof. Kempadoo also acknowledged that the category of "rights" (especially legal rights) has its built-in limitations and doesn't preclude questions about serious issues of alienation which has often been pointed out as more heightened in sex work, because of the place sexuality occupies in many societies. Because many societies attach a gamut of beliefs around identity, relationships and at the same time, stigma around the sexual, "sex workers rights" isn't really a comprehensive articulation of the issue of prostitution in as much as it is a strategic claim.
Prof. Ashwini Tambe, of the Women and Gender Studies Institute and Department of History, University of Toronto meanwhile challenged the participants to question prevalent thinking about prostitution and trafficking in absolutist terms. The usual way of representing the positions vis a vis trafficking and prostitution has not only led to conflating one with the other but also tends to reinforce the discourse as solely about being anti/pro legalization, anti/pro prostitution/trafficking.
Within social movements, while many feminists still stand divided about the legal questions about prostitution and trafficking, there is still admittedly a huge difference between the position of "traditional" and religious-based positions on prostitution and feminist ones.
One more question which emerged from the discussion was whether a big part of the debates within social movements has to do with unquestioned notions about the law, particularly the use of criminal law to "solve" social problems. As useful as penal law strategies have proven in making that initial step towards the recognition of "Violence against Women" (VAW) as wrongdoing, what is the net effect of exclusively invoking the coercive (police) power of the state in the context of rights protection?
For the participants of the forum, many of whom were law students, the discussion that followed proved to be a valuable source of insights about the limitations of legal categories and strategies as well as the many paradoxes of legal theory and practice, in relation to the construction of harm in the context of and alongside sexual acts. Law students were ready to admit how their concern for trafficked women in prostitution usually arises out of an idea and image of "victimhood" that is somehow constructed and reinforced by law.
Indeed, while the notion of a "victim" in law structures liability, in practice it also plays out as the requisite of "legitimacy" when women seek and claim protection. In other words, law shapes what women should be (as victims) worthy of protection.
This whole idea of "worthiness" (in making claims and seeking protection and assistance) also plays out in familiar schisms between some "child rights" and "women's rights," positions. This is also seen in the context of anti-trafficking campaigns which privilege "child trafficking" and ends up serving as the dominant image to represent all experiences (including women's experiences) in trafficking and prostitution.
PEPFAR, in accordance with its worldview of sex, divides up the rest of the world's civil society groups doing anti-trafficking work into the pro/anti prostitution. Often compared to the "Global Gag Rule" or the Mexico Policy which precludes USAID funded organizations doing family planning work to from having anything to do with addressing abortion, PEPFAR's far reaching consequences goes beyond the selective distribution of funding in HIV/AIDS programs.
In the short feature, "Taking the Pledge" by the Network for Sex Work Projects, groups working on massive education and empowerment campaigns within sex workers networks from Thailand, Cambodia, India, and Brazil spoke about the adverse impacts of the US "Anti-Prostitution Pledge" embedded in PEPFAR. In each case, groups offering services which were most accessible to sex workers were eventually denied funding because their position on prostitution was not up to PEPFAR's standards.
The "anti-prostitution" oath not only tends to push the agenda of prohibition vis a vis prostitution, but also favours strategies that are categorically "law focused" (the passage of anti-trafficking and sex trafficking law) and penal in character, criminal prosecution over health based interventions that reach out to educate sex workers. While addressing any harm logically entails penal law, the construction of "harm" in this case, goes well beyond listing what "trafficking" entails alongside stringent penalties. PEPFAR also foists upon its aid recipients, a categorization of the worthy and unworthy. As "US foreign" policy, it adds another whole dimension to local politics in the South around trafficking and prostitution. The end result of course is the exclusion of sex workers from the South from the recipient list of program interventions. Within PEPFAR's framework, sex workers from the South are clearly the undeserving and unworthy.
]]>In 2006, the Guttmacher Institute, collaborated with the local University of the Philippines Population Institute (UPPI) and released its latest research on the incidence of abortion in the Philippines showing that an annual rate of over 473,400 (27 per 1,000 women). While this study is based on data as far back as 2000-2002, it is the most recent source of data on abortion. Indeed, there have been no other studies on abortion apart from the UPPI and AGI initiatives in 1998 and 2006 respectively.
One of the more interesting findings is that the stereotype of who usually undergoes abortion and why (in the Philippines) doesn't exactly fit the hard data.
Arguably, stereotype of a woman seeking abortion in this country involves "young girls in trouble." Even the age-old criminal statute portrays the stereotype of young women as the primary seekers of abortion, imposing a different and lower set of penalties when young women (their parents included) commit abortion because they are motivated by "concealment of dishonor" (these are the actual words in the law).
While indeed the study noted that over 46% of attempted abortions are still among young women (aged 24 and below) the majority of women actually going through abortions are actually Catholic mothers with already three or more children, married and/or living with a partner. The majority of these women either have a high school or college level education (7 out of 10), but majority are also poor (also 7 out of 10).
Of course an alarming data gap is the actual percentage of maternal deaths and health complications because of botched abortions. We know for a fact that the maternal mortality rate in the Philippines remains alarmingly high (162 as of 2007) Despite the statistically insignificant "decline" (from 172 in 1998), the Philippine government has actually claimed a significant decrease in maternal deaths. To do this, it neglects to mention the 1998 data and compares the current rate of 162 to 1993's closer to "209" maternal mortality rate.
But the "spin" on maternal mortality figures by the national government is hardly the only problem.
Arguably, government's political posturing against abortion and reproductive rights issues has largely been in reaction to the vocal Catholic hierarchy. On the other hand, there are indications that the usual "fire and brimstone" approach isn't doing the job anymore. Noting that recently, a group of Councilors in Quezon City stood firmly behind the passage of a Reproductive Health Ordinance in spite of some Bishops' denunciation of the measure, Philippine Daily Inquirer Columnist, Rina Jimenez David observed:
This tells me many things about the Church's campaign against reproductive health and rights. One is that the name of the game for the Church is intimidation, and only because the bishops know they have already lost the public opinion war on the issue of family planning. Another is that the Church will "win" only when legislators and policymakers allow themselves to be intimidated, or put politics before the greater good. And yet another insight is that despite the Church's incendiary rhetoric, nobody really believes it. The world is not going to end because teenagers are taught to use the condom or because women learn how to pop pills.
Given such a development, one of the surest ways forward would be to challenge conventional avoidance of open discussions about the issue of abortion, and to aim for a dialogue - hopefully one that doesn't end up oversimplifying the issue as a matter of sin, but as a matter of law.
]]>Meanwhile, within weeks of the Manila petition, Manila's next door neighbor, Quezon City, passed an ordinance premised on the notion that "sustainable social development is better assured with a manageable population of healthy, educated and productive citizens."
Earlier, some of the authors who were themselves Catholics expressed unpreparedness for the vituperative labeling and name-calling from the Catholic opposition led by the hierarchy. Clearly still reeling from the incessant attacks, with one Bishop calling the ordinance "anti-life" and a "threat to the sanctity of the family," Councilor Ariel Inton made sure to stress that "the ordinance does not legalize abortion with the measure." He also insisted that the policy is "consistent with the Catholic church's position."
Well meaning as he is though, the official Catholic Church's position couldn't be clearer. Equating all manner of contraception with abortion, any measure to provide these services has been met with resistance by the Catholic hierarchy in the last seven years at both the local and national level. The case would be different of course if Inton were referring to the "Catholic view" held by "most Filipino Catholics," (specifically women who prefer the pills as their method as reflected in the National Health Demographic surveys). Indeed, most Filipino Catholics just as most American, Brazilian or Mexican Catholics have more liberal views about family planning. Yet Inton's defensive posture is a familiar politician's stance in the Philippines. Even in the course of drafting bills before Congress on reproductive health policy, many representatives have often come up with similar suggestions of articulating a "disavowal" of abortion in the bill, even if the bill was never really meant to go as far as amending the penal law on abortion.
Likewise, it is relatively well understood that a City can ever amend a national law anyway. The Quezon City initiative merely implements already existing legal mandates for local governments to provide family planning in the Local Government Code. But it seems that not all local chiefs are intimidated by the Catholic Church. South of the Philippines in Mindanao, another Mayor has taken up the cause of getting emergency contraception re-registered
Davao City Mayor Rodrigo Duterte has been working for over a year now to secure the Emergency Contraceptive Pill (ECP) for the City's rape crisis centres. Also well known as one among the few cities in the country to first enact local legislation addressing Violence Against Women (VAW), (even before Congress passed the act) Davao City also has a very active Gender and Development Office that works with local women's organizations.
The big difference of course is that Duterte's efforts are not getting any support from the national agencies tasked with the re-registration of ECP. (And this is putting it politely.) Over four years ago, an Experts Committee created by the Department of Health (DOH) came out with a sixty-three page recommendation vouching for the safety and efficacy as well as the legality of ECP under Philippine laws and regulations. Yet on the heels of the corporate applicant's withdrawal of its application, the Secretary decided to forgo a final decision on the recommendation and set the case aside for lack of an interested applicant.
Unfazed, Mayor Duterte announced his intention to take action sans a corporate applicant and as local government chief, seek an application on behalf of the city in December 2006. Davao is one of few cities with funded rape crisis centres and hospital based women's protection units. ECP to prevent unwanted pregnancy in rape and sexual abuse situations is a common regimen alongside counselling, support services and forensic evidence gathering contexts. Working to suppress and delay ovulation, ECP taken within seventy two hours from unprotected sexual intercourse can prevent pregnancy. It saves many women, especially those in situations of rape and abuse, from further psychological trauma of an unwanted pregnancy.
The Mayor's position is perfectly legal and has basis in the decentralization policy that put health care delivery under the local government units. Procurement of essential medicines for the local government is also part of this mandate. However, it seems this Mayor is being given a run around. For over a year, his office has been waiting for what the BFAD refers to as a review being undertaken by a "technical committee" of obstetrician gynecologist specialists.
Unlike the 2002-2003 review which observed BFAD and DOH regulations on the conduct of a "public" hearing, (that is it was open to the public despite having been conducted usually late at night), this time, the members of the so-called committee were not even disclosed to the public.
The BFAD's curt and brief response does not even say what new issues are before it since the earlier recommendation by a panel of experts hired by the DOH to do the same thing was never over ruled anyway. Are these the same issues on safety, efficacy and legality? Why is the mechanism of action open for debate all over again? Has the past Panel of Experts been discredited? The BFAD doesn't say. It just tells the Mayor and his City to wait for the final outcome of this very "mysterious" review process.
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The Executive Order was issued by the former Mayor, Lito Atienza in 2000 and on paper "discouraged" the use of "artificial contraceptives," in the city's health and family planning programmes. For many years, advocates who wanted to challenge the order were unable to simply because nobody could produce the supposed policy. Not even local barangay (the smallest local government unit) chieftains at the community level could show advocates a copy of the order but swore they were informed by the Mayor's office it was very much in place.
In the past other local government officials also instituted similar "bans" at the provincial and city levels. Former Governor Joey Lina was said to have instituted such a ban during his term as Laguna Governor as early as the late 1990s. The former Puerto Princesa Mayor in the province of Palawan also imposed a similar ban in 2001.
What perhaps set the Manila ban apart was the sheer determination and political influence of its proponent, Mayor Lito Atienza, who was also the national president of Pro-Life Philippines when he was Manila Mayor. In fact, more than relying on a written policy (which no doubt the Mayor also shrewdly noted could always be questioned legally), he also systematically put into place, city health officials and employees (right down to the barangay health level) with his appointees who shared his restrictive beliefs on contraception.
Slowly but surely over the Mayor's nine-years in office, he was able to make both local officials and even hospital administrators comply with a policy that not only lacked legal basis but was also for many years, only vaguely (and inaccurately) alluded to as "an ordinance."
Even medical practitioners in the city-funded hospitals who were well aware of the legality of modern contraceptives and family planning methods such as surgical sterilization disclosed that it eventually became impossible to conduct these procedures when the hospital administration gave them warnings direct from the Mayor's office.
In the end, more than a written legal policy, the Mayor's main strategy to gain compliance was clearly also connected with his administrative power of control over the budgets of both barangay units and hospitals. Advocates responded by keeping the issue on the agenda, at times also gaining the ire of the Mayor who at one point announced a crackdown on "abortion clinics," all the while referring to family planning clinics giving out contraceptives. Keeping the pressure on in media, advocates were also featured on an on-line publication called "Medical Observer," where women's rights advocates working in health care and providing services in Manila, continued to criticize the baseless policy. On this occasion, an over-zealous apologist for the Mayor wrote to the editor of Medical Observer and proclaimed that the Mayor's acts had legal basis, and he cited the "Executive Order" which was issued in 2000. Ironically, the information on the exact number and date of the policy came straight from the Mayor's most ardent supporter. This allowed advocates to finally pinpoint the policy and later access it from the City's records office.
But the even greater irony of course was that in order to even bring the issue to court, a lot depended on more sacrifices on the part of women who themselves were already under the most pressure in Manila: those who were deprived of the services; denied access and experiencing direct discrimination and harm. Once more, theirs was the burden of bringing this issue to light.
The study conducted by the Center for Reproductive Rights and its local women's NGO partners last year entitled "Imposing Misery," already confirmed that indeed, there were many women who already experienced and were continuing to experience the harm because of the Mayor's policy. From being forced to make hard choices about risking pregnancy and allocating the meagre family budget to feed the family right down to the pressure of risking clandestine abortion, the report outlines the havoc the policy has wreaked upon the lives of Manila's poorest women. In the study, doctors from the city funded hospitals also noted the ever rising numbers of post abortion emergency cases that the hospital has had to deal with, making a direct link between the rise in abortions and the Manila policy.
Yet women also suffered the indignity of being paraded by the Mayor in his pro-life politics. At times they were given cash incentives and rewards that clearly augmented their family needs, but were also given publicly during the Mayor's sorties, as "a reward for having many children." These poor women were the convenient "campaign fodder," for the Mayor who was obviously only interested in projecting a popular public image of support for his position. The women who accepted the Mayor's "gifts" actually had little choice. In many ways, these cash rewards were barely even enough compensation for what the Mayor was already putting them through by his denial of basic health care and family planning.
Framing the legal issue as one of women's rights to reproductive health and family planning, Counsel for the Petitioners, Atty. Elizabeth Pangalangan (who is also a Professor of Law at the University of the Philippines) notes that the policy not only contravenes local laws like the Constitution and the Local Government Code but also international human rights standards.
Yet even as these claims are finally getting litigated in court, another challenge that advocates confront is the ensuing clash of positions which because of the Mayor's pro-life politics, has always tended to be framed as an issue about his "religious beliefs."
The policy itself very much reflects the Mayor's imposition of his "traditional Catholic views," which on the other hand, is hardly the only Catholic view on the matter. In fact, alternative and differing positions within the Catholic Church are well known elsewhere around the world not only around contraception but also HIV AIDS and abortion.
Womenlead Foundation, Inc. Executive Director, Atty. Claire Luczon notes: "Neither constitutional law, international law nor Catholic teaching on conscience supports any form of state imposition of religious beliefs, in this case, banning a legally mandated component of basic health and family planning at the local government level."
Arguably, there is hardly anything religious let alone moral in restricting women's access to health care and endangering their lives. In an opinion piece, Dr. Sylvia Estrada Claudio a Fellow of the Action for Economic Reforms underscores the importance of the case filed by the women of Manila:
"Within the context of this discrimination against them, the high point of the narrative lies in the women petitioners' nobility. Most of the petitioners cannot regain what they have lost. When asked, many of them say they are doing it for the sake of all women who still need and seek the means to decide over the size of their families. They remain fearful of reprisals even if a new mayor now sits in City Hall. Politicians of Atienza's mold strike fear into the hearts of those who disagree with them. That fear, no matter what his allies say, is not one that comes from Atienza's moral rectitude or his closeness to an avenging god."
]]>A War of Wor(l)ds: The Politics of Reproductive Health
"The theoretical links between reproductive health, gender and sexuality constitute a complex and unstable fabric." Sonia Correa (2005)
Sexual and reproductive rights activist Sonia Correa notes that historically, "reproductive health" emerged as an "umbrella" term after the 1994 International Conference on Population and Development (ICPD) in Cairo and the 1995 World Conference of Women in Beijing, within which "radical" notions of reproductive rights and sexual health, as well as issues related to sexual rights, were initially subsumed.
However, the legitimization of the term "reproductive health" eventually led to its use in ways that responded to the needs of different interest groups and actors, which no longer necessarily incorporated the frameworks of gender equality and socially transformative agendas.
The Media's Discussion of Reproductive Health
In 2007 in the Philippines, much of the popular debate around reproductive health in the country was still happening on the basic level of legitimation and recognition. Popular media was engaged on all sides of the discussion but media was rarely a source of enlightenment.
Even as a handful of local reporters and columnists in major newspapers like Rina Jimenez David, Michael Tan, and Dr. Alberto Romualdez were leading the discussion of "reproductive health" as rights, many in media continued to frame the debate simplistically as a case of "Catholic Church versus the Population Control forces."
Reporters continued to label "RH advocates" as population control forces and align the RH bill with population control policy, harking back to the days of the Marcos dictatorship when policy around population was backed by a demographic imperative in the Constitution. In turn, it had the tendency to portray the Catholic hierarchy's position as an opposition to a supposed push for draconian State policy.
In truth, neither population control nor the Catholic hierarchy's conservative anti-reproductive health positions respected the right of persons to decide on their reproductive well being. Likewise, the 1987 Constitution as well as subsequent commitments made by the Philippines to the ICPD and the Beijing Platform demonstrated a clear departure from a population control framework. Unfortunately, many in media still missed out on this distinction and save for the better informed journalists, and the popular discussion of the issue continued to be framed along these terms.
RH advocates fought back, of course, with a measure of success in not only updating allies within media on the rights-based character of claims for reproductive health services, but also in addressing the most difficult but pressing issues like clandestine abortions. Reproductive Health Networks like Philmade and Media Advocates for Reproductive Health (MAHRE), have made headway in many areas, especially among local media networks.
In a previous blog I noted how MAHRE and Likhaan, a local women's NGO advocating for sexual and reproductive rights, recently turned things around by zooming in on the rising trend of abortions in the Visayas region in the Philippines. MAHRE and Likhaan even got sympathetic write-ups in two editorial/opinion pieces (see another here) in local media, demonstrating the way forward to compassionate and sensible discussions on what was always perceived as a divisive issue.
Meanwhile, dominant media continued to rely on "abortion clinic raids" as sensational news staples. Unlike their local counterparts in media which were already beginning to take a more sober and informed approach to tackling the issue of abortion, popular, self-styled "crusading" journalists on TV reported on abortion clinic crackdowns without delving into the complexities of the issue or even bothering to ask why despite the more than hundred year old prohibition, studies continue to peg abortions in the Philippines at 473,000 cases annually.
The Global Gag Rule Contributes to Sensational Treatment of Abortion
Indeed, policy against abortion is also clearly at the heart of the "Republican/Democratic" ideological divide in the US. There, the existence of policies like the foreign assistance policy on reproductive health, the global gag rule, which requires that groups receiving funds for family planning pledge not to discuss abortion in any of their programs or materials, and AIDS prevention and treatment standards prioritizing abstinence, have always solely depended on a Republican presidency.
Notably, this conditionality represents a curious programmatic imposition on local advocacy and essentially places limits to "information and expression" since legally speaking, the conduct of abortion is always subject to local law anyway. In the Philippines, abortion (save for a debated exception to save the life of the mother), remains illegal. The "global gag rule" serves purpose parallel to that of the sensational "abortion clinic raid" by keeping the issue in its current place: surrounded by stigma and well outside the realm of public discussion and deliberation.
Yet the links between the US and the Philippines (specifically on matters of reproductive health and policy) go well beyond the issue of abortion or the global gag rule. The Philippines, as a long time recipient of USAID funding on matters of population, health and, in recent history, "health sector reform," is also facing a crisis in health care availability. Coupled with the mass migration of health professionals, the crisis is not only one of access to health care but availability itself. While originally pitched in the eighties as "structural and systems based" reform, "health sector reform (HSR)" is has become the literal byword for undertaking (further) privatization of health care in the country. The USAID has had a keen interest in facilitating "HSR" in the Philippines where a number of technical assistance projects emphasize the privatization of public hospitals. Indeed, while the final outcome of US Presidential elections in 2008 will surely have an impact on local (as well as worldwide) politics around reproductive health, a great deal still depends on how local advocates are able to face both opportunities and challenges that emerge from it.
Next week: News on the Court of Appeals Petition filed by women in Manila to invalidate the ban on contraceptives in the City's local health services, instituted since 2000.
]]>Last week I took a look at how reproductive health advocacy in the Philippines in 2007 got caught in Presidential politicking despite growing support for the RH bill in Congress.
On the other hand, the first successful passage of a local RH ordinance was by the Oppositionist and former Congress RH and Women's Rights Champion, Bellaflor Angara Castillo. Angara Castillo was elected as Governor of Aurora Province in 2004 and she set an example by passing a Provincial Reproductive Health Care Ordinance, that necessitated the unity and backing of her Provincial Council. Working closely with Reproductive Health Advocacy Network (RHAN) and the Philippine Legislators' Committee on Population and Development (PLCPD), her draft bill soon became the basis and model for drafting key RH Ordinances around the country
Two major cities of Metro Manila became the focus of attention largely because of the level controversy that surrounded policy advocacy in these areas.
The Center for Reproductive Rights in partnership with local women's organizations launched a study on the Manila situation called "Imposing Misery." In a previous blog I discussed how this study outlined the violations of both local and international standards by the policy adopted by the former Mayor. The report also provides a glimpse into the lives of the women who bore the brunt of the Manila ban.
While the current Mayor, Alfredo Lim who replaced Atienza (his bitter rival) is also "a professed devout Catholic," his views about modern contraception remain unclear and advocates have made a bid to find out how far he is willing to challenge his rival's former policy.
The adjacent City, Quezon City ,is also currently the site of an RH initiative. By the end of 2007, local champions of Reproductive Health who courageously sponsored an ordinance found themselves smarting from a debacle that many of them considered unparalleled in their political careers. It seemed nothing had prepared the local politicians for the vituperative labelling and name-calling that ensued when they sponsored the ordinance.
One of them was Joseph Juico who also considers himself very Catholic, was surprised at the viciousness of the personal attacks from other Catholics, but vowed to forge ahead.
When she was invited to come along and observe one of the sessions tackling the QC RH Ordinance recently, Atty. Claire Luczon, Executive Director and Legal Committee Chairperson of RHAN observed: "The opposition to RH fell back on usual tactics of trying to scare everybody about abortion, and it was a real circus."
She also added: "What I didn't expect was to deliver an impromptu presentation on Reproductive Health Policy. Yet I think the opportunity was very important in a sense that in these heated debates, a lot of the misinformation needs to be addressed in order for the discussion to move forward. Apart from requiring cooler heads and more evidence based data, talking about women's health issues necessitates more kind-hearted approaches, and its due time we set the record straight on reproductive health."
Womenlead's Executive Director has been requested by the City Council to come back as a resource person, giving RHAN and other local RH advocates some hope that this time, reproductive health care will be better understood as part of respecting and promoting people's human right to health.
Reproductive Health Advocacy Network Secretary General, Gladys Malayang, notes that even with the continuing challenge of moving along the RH bill within the legislative mill, the network and its members also plan to concentrate on local initiatives at various local government levels in 2008 because "building and strengthening its mass base," is part of the overall strategy of building up its constituencies, locally and nationally.
Meanwhile National Advocacy Officer of the Philippine Legislator's Committee on Population and Development (PLCPD), Kala Pulido-Constantino acknowledges the tougher than usual year that was 2007 and adds that what makes the 14th Congress a tougher nut to crack is because it precedes Presidential elections in 2010:
"I think advocates have to start thinking of the presidential elections. We need a president who will support RH without reservations. We need to continue our national advocacy without any illusions of getting a bill passed or changing executive policy. But we cannot give up our political gains, our public space which the Church adamantly wants to narrow down."
]]>Because Filipino Congressional elections were held in May last year, reproductive health advocates faced tougher-than-usual challenges in 2007. Filipino politicians more interested in re-election began posturing for the upcoming elections early in the year, losing interest in the passage of urgent legislation. For the embattled President Gloria Macapagal Arroyo, who faced impeachment charges before the 13th Congress, ensuring her allies' political dominance in the 14th Congress was no less than a bid for political survival. And although controversial largely because of the Catholic hierarchy's sentiments against it, the Reproductive Health Bill never really lacked champions in Congress, a number of them even from the President's party. On the other hand, President Gloria Macapagal Arroyo was always the bill's most consistent opposition in government. Under her influence, even the Department of Health began a focus on "Natural Family Planning" (NFP), to the detriment of its more comprehensive reproductive health and family planning programs of previous years, under different administrations. Even past budgets for family planning and reproductive health successfully passed in the previous Congress ended up unspent in 2007, blocked through bureaucratic impositions by the President.
Among these many challenges, I discuss three key themes, the politics of reproductive health policy making and spending, media's coverage of RH and finally local initiatives in RH advocacy. In the last part of this three-part roundup, I also discuss the RH movement's most urgent challenges in 2008, also incorporating the views of experts and advocates in the field. I especially focus on RH in the context of the overall status of health policy and what remains of the threatened local public health system.
Reproductive Health's Strange Bedfellows
Bills on reproductive health which faced an uphill battle ever since they were filed in the 12th Congress (2001-2004) had only till then reached the Committee level. By 2006, a version of the Bill sponsored by Rep. Edcel Lagman, came even closer to being passed before the House of Representatives in the 13th Congress, and was inches away from floor deliberations that could have ensured its adoption in Congress and eventual transmittal to the Senate for approval. By end of 2006 however, it seemed, all bets were off all over again.
While advocates faced the challenge of elections head on by helping focus on the issue of health care within political agendas and platforms, when the dust settled, GMA's allies had won a majority of seats in the 14th Congress. Yet as just like the past Congress, support for and opposition to Reproductive Health measures didn't necessarily fall along party lines. Finding its staunchest support in some of the administration's party members, versions of the Reproductive Health Bill were filed anew before the 14th Congress that convened in July. By August, the champions found themselves under attack again by the Catholic hierarchy's lobby.
Representative Janette Garin, who hails from Iloilo (a province where the Catholic hierarchy remains powerful) attempted to assuage RH's staunchest Catholic critics by proposing a bill that only focused on "information dissemination" about family planning methods. Yet in response, legislators on the side of the Catholic hierarchy led opposition to RH suggested that the measure should first be taken up and discussed with the Catholic Church since the President listens to the hierarchy. Digging her heels, Garin, who is a Medical Doctor by profession appealed for an informed debate about the issue of Reproductive Health and rejected the suggestion, pointing out that the legislative branch and executive were separate co-equal branches and that Congress in its law making mandate need not seek the approval of the President.
She could have (and should have) also noted that consulting the Catholic hierarchy and seeking its approval would also have smacked of violations of no less than the Constitutional principles of non-establishment and the separation of church and state. The fact that majority of institutional religions like the Iglesia ni Kristo (Church of Christ), the United Church of Christ of the Philippines (UCCP ) and even Muslim clerics who issued a fatwah (official ruling) in support of RH shows the extent of the influence of the Catholic hierarchy, that is mostly over Filipino politicians. Majority of Filipino Catholics have always professed to favour modern family planning methods, leaving these matters according to their own exercise of conscience, rather than the dictates of the Catholic hierarchy.
Yet another champion of RH from the ranks of the administration's party, Rep. Edsel Lagman decided to up the ante in the RH debate. Instead of trying to appease naysayers of RH by avoiding the terminology of Reproductive Health, he made a bold decision after consulting with advocates to place it front and center in the earliest version of the bill filed in the 14th Congress. (In previous blogs I have noted how even Lagman's earlier bill's was one of many versions which "avoided" reproductive health by burying the term within the bill and adopting "less suspect" titles.)
Lagman's move was a welcome change and one that signaled the comeback of reproductive health's legitimacy. For many years since Arroyo became President, "RH" was labeled and singularly equated with abortion by its critics. This made it difficult if not nearly impossible to discuss reproductive health and even abortion intelligently and compassionately (even as its legalization was never a part of the legislative measure).
Death by Red Tape and "The Catholic hierarchy's watch dogs"
Soon after the 14th Congress convened, Rep. Lagman began inquiring about the budget and line items for family planning and reproductive health services for the Department of Health (DOH), and whether these funds were ever utilized.
He soon discovered that while the President didn't veto the line items per se, she made the release of funds conditional on the creation of guidelines, and Memorandum of Agreements executed between the DOH and the local government units for which the funds were intended. In August, the Philippine Center for Investigative Journalism disclosed while some of the conditions depended on the capacity of LGUs to provide free assistance for poor clients, one particular condition being imposed is that "clusters of LGUs can only be awarded funds based on their ability to meet the minimum standards on local availability and access to natural family planning."
While initially unfolding as a "tug-of-war" between the two branches of government, in the end, the Executive's stubbornness prevailed with the DOH Secretary insisting that spending for contraceptives is not in accordance with the GMA administration's policy whose aim is only to strengthen "Natural Family Planning."
In fact, as early as 2004, the DOH even awarded 50 million pesos to a Catholic organization, the Couples for Christ (CFC) to conduct the NFP program. And while advocates have come out in criticism against this move, it only got as far as becoming the subject of a Resolution filed by no less than opposition Senator Luisa Ejercito (wife of the former President Joseph Estrada), calling for an investigation into the highly "suspect" government award which did not go through bidding.
By September last year however, news about a fall out and a split within the ranks of the Couples for Christ reached the media. Tony Meloto, the leader and founder of a key project of the CFC called "Gawad Kalinga," a housing project which had till then garnered accolades and often compared in its success to the Grameen bank, was under attack by the more conservative wing of the CFC represented by Frank Padilla.
It seemed that while neither faction differed in their views about family planning and echoed the Catholic stance against modern methods, Padilla thought Meloto and his camp were being too inclusive in running the housing project which benefited not only Catholics who differed in their views about family planning, but also other communities like impoverished Muslim communities.
Yet rather than a minor skirmish, the power struggle within CFC also reflected the rise of the departing faction into "official" power within government. Many of them have secured key posts.
Frank Padilla's wife holds appointments to both the Population Commission currently under the Department of Health and the National Commission on the Role of Filipino Women (NCRFW). Both positions place her well within policy making, among others, in matters of women's sexual and reproductive health.
According to PCIJ, another Presidential appointee in the POPCOM, Jose Sandejas is a close adviser of the Archbishop of Pampanga, Paciano Aniceto, and has been a trustee of Pro-Life Philippines since 1987.
PCIJ's Jaileen Jimeno aptly noted, "Arroyo's political accommodations in favor of the Catholic Church are also clear and out in the open, leaving even career government officials in fear of losing their jobs should they go against the anti-contraceptives policy."
Unfortunately, despite the bravado of legislators and RH champions among law makers, GMA has proven more the more brazen. Apart from frustrating the realization of reproductive health care through the politics of red tape, by handing out key posts to persons closest to the Catholic hierarchy, she succeeded in sending a clear message to everyone else under these key agencies. As things stand, the Catholic hierarchy literally has all the agencies strategic to any state led reproductive health program by a chokehold.
By November 2007, Rep. Lagman and his allies in Congress were again being lauded for the increased budgetary allocation for health for 2008. This early we can already predict tirades anew back and forth between the two branches and notably even within the President's own political party. But last time I looked there are actually three branches, lest we forget the recently applauded independent "pro human rights," judiciary. Indeed, given how the GMA administration has consistently quashed the reproductive health allocation in the past, the question that begs asking really is what are advocates willing to do this time around?
]]>Looking back I think the reason it got so unbelievably hurtful was that I always remembered her as a feminist in college. I don't think it was just me that had this impression, but now that I think about it, I realize we never really had much of chance to talk about abortion specifically. A lot of it was also youthful arrogance -- hers and mine. Admittedly, while I have the same position on women's right to abortion now, as a much older feminist, I know some things a little bit (at least a tad) better now. I know not all feminists agree with abortion (or for that matter a lot of other things) and I certainly recognize that this issue is so much more than the boxes many of us (especially popular media and law) have placed them in. Abortion isn't about "Pro-Life" or "Pro-Choice," those arbitrary slogans whose meanings get lost in the feeble line-drawing games people play. Women who have abortions don't always know where they stand about these things and yet passions flare, feelings get hurt and friends lose touch.
And when people lose touch, they stop talking and that is the most dreadful part of it. Over the years as a feminist who has publicly spoken about women's right to safe abortion (where I come from many feminists still feel threatened about doing this), I have also quite surprisingly maintained friendships with women who consider themselves against abortion because of their religious beliefs. Many of them are also in human rights work and have always come in support of my work in women's rights.
Two years ago, feminist friends who come together every now and then to discuss sexual rights and abortion back home came up with an idea for a workshop. Instead of using the usual pro/anti binary someone suggested that we come up with our descriptions about how we felt towards abortion. We didn't confine ourselves to either law or medicine but were free to categorize where it was we stood on the issue. The result, and the views expressed, while not exactly original (I recently read a book that describes similar stories from Latin America), was nonetheless an eye opener.
While some women tried to reconcile their views with their understanding of science and religion (i.e. emergency contraception, early term abortion) some aligned their positions on specific women's situations, particularly when left without options or when suffering injustice (rape, incest and fetal abnormality). Some women were also able to simply trust women's individual judgement, citing women's capacity to make the decision as the sole basis. And like the stories of other women elsewhere, there were women who admitted they always stood against it until they had one themselves.
Yet what was perhaps even more groundbreaking than hearing the continuum of positions was the simple fact that it actually felt easier to breathe after that exercise. Knowing that each was accepted under her own terms of accepting the issue made the meeting all the more extraordinary. Being accepted and respected all the more made accepting and respecting others important.
In my line of work as it is I suppose for the lot of advocates who keep the fires burning for the cause of sexual and reproductive health as human rights, it is encouraging (and heart warming) to know that our work can open doors. In seeking recognition for women's rights and standing up against injustice, it really isn't (and shouldn't be) a "war" about an "us" and "them," but rather an opening up to ways of thinking, levels of meaning and feeling.
Ultimately, even when it feels like we stand across pre-drawn battle-lines in this debate, and there will always be times when this feels exactly like a war with little understanding -- hopefully there will still be a chance for sober talk and compassionate dialogue. It isn't easy and it always entails a risk of stepping out of our comfort zones but every now and then it pays off. At the end of the day, we might not end up having the exact same views and positions but it may bring us closer to being more open and sensitive to understand where each one is coming from.
A few weeks ago I took the plunge and went out on limb and emailed my friend after seeing her email in a list. It took her a few days to write me back but when she did, she was warm towards me and we didn't even have to dance around the topic. It was there in front of us, our lives somehow taking a turn where our views on abortion are figuring prominently as ever. She had decided to study again, and this time is taking up nursing. I on the other hand am doing graduate studies in law on a Reproductive and Sexual Health Fellowship.
We acknowledged where each of us stood, a bit sheepishly at first but because we were also older (some ways wiser or patient), we talked over the phone and listened to our differences melt away. We still feel differently on abortion and stand apart on the issue of law, science, medicine but who knows where else? We haven't really dug in to ethical aspects yet but I'm looking forward to it as much as we look forward to exchanging pictures of our loved ones (proud mothers as we are) and keeping in touch.
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Yet the questions being raised by feminists at the forefront of sexual and reproductive health advocacy don’t really just focus on the types of medical care available or their touted scientific benefits but rather remain attentive to issues of social justice.
Presenting at the Banff National Health Conference, Professor Joanna Erdman Co-Director of the Reproductive and Sexual Health Law Program at the University of Toronto, posed direct challenges to existing frameworks on health law and policy. In her paper, she took on the built-in limitations of an approach she characterized as the “technological fix,” in relation to the recently approved Human Papillomavirus Vaccine (HPV) in Canada.
The HPV Vaccine, which protects against the human papillomavirus, a leading cause of cervical cancer, instantly relit a hotbed of issues related to women’s (and young girls’) sexuality.
The vaccine’s efficacy in preventing HPV infections (which can lead to cervical cancer) is said to be most effective if introduced between the ages of 9-13 (up to 26 years), before the initiation of sexual intercourse.
Because of this, pre-teen and teen-aged girls became “the target” population of Canada’s health program. As expected, controversy erupted anew around parental consent to concerns about “promoting promiscuity” among young girls.
Yet, she warned that behind the Canadian government’s commitment to instituting “universal” programs aimed at girls in schools, a “technological myopia” is evident in coming to the conclusion that simply undertaking a universal vaccination program in schools will take care of the problem of cervical cancer.
In doing so, she pointed out how the policy seems to have made a leap in considering the innovation as the solution, much to the neglect of issues of equity.
In order to understand the social and legal issues better though, the medical aspect of cervical cancer, HPV and the vaccine, need some consideration. While over half of all sexually active women in North America aged 18-22 are said to be infected with HPV, in most women, the infection clears up on its own. In cases where it doesn’t, the infection can lead to cervical cancer.
Persistent HPV infection is further classified by doctors as low risk and high risk infections. High risk infections are not at all the same as cervical cancer and the progression rate (high risk infections leading to cancer) is at one percent. In a given year, among 1350 diagnosed cases of HPV in Canada, the number of deaths reached 390, with a notable higher rate among aboriginal and migrant women. (In fact, over 80 percent of cervical cancer cases are in the developing world.)
This alone, Prof. Erdman pointed out illustrates how the risks of developing cervical cancer are in fact systemic and barriers to access are multiple.
Gardasil, produced by Merk-Frost Ltd.in Montreal is said to be the most expensive vaccine ever developed for mass use, with costs reaching up to 404.85 Cd dollars for a three course treatment. (Pundits have written a lot about this issue including how Merk came up with its price tag)
Indeed, while Gardasil works like other vaccines, HPV isn’t like most infections. While the vaccine works by preventing a known virus which can lead to cervical cancer, the mode of transmission of HPV is sexual intercourse.
Interestingly, Professor Erdman raised how in the marketing of the vaccine, it underwent a strategic repositioning of the drug from addressing a known STD infection, to that of a “cancer prevention” vaccine.
Despite the recognized benefits of universal programs aimed at young girls, there is still a need to raise concerns about the question of more likely vulnerable and disadvantaged groups of women, simply falling through the cracks. The Canadian universal school-based federally funded program was pegged to have a hefty price tag of over 300 million.
Meanwhile, the school-based program is basically a one-time intervention and has nothing to do with the overall structures of the health system, nor is it integrated in reproductive and sexual health programs. Likewise, receiving the vaccine does not remove the necessity of regular screening later in life.
Indeed, rather than looking at the vaccine as some sort of “cure all,” that will save all women from the dangers of cervical cancer, Prof.Erdman emphasized the continuing importance of screening for cervical cancer. In the long run, an effective health system still needs to make screening procedures available (mainly the pap smear and in limited resource settings, the acid wash) which by themselves, remain inaccessible to disadvantaged groups of women.
]]>It was a full day packed with a diverse array of topics in health law and policy on the second day of the Canadian Conference on National Health Law entitled "Visions," by the University of Alberta's Health and Law Institute.
The overall theme was the "new," in terms of emerging research challenges, liability issues, technologies and paradigms in health law.
Emerging Research Challenges
Professor Trudo Lemmens, Associate Professor at the University of Toronto, Faculty of Law, opened the morning session with a discussion of Genetics and Health Information Privacy. He noted, hot on the heels of emerging new technologies in the field of genetics, the call for "openness" -- a familiar rallying call by both scientists engaged in research and development (R&D), industry pundits and corporations.
"Biobanks" -- which are literally stores of genetic information (The Human Genome Project is one popular example) -- are increasingly being advocated as part of "publicly available" information.
"Biobanks" -- which were in their inception aimed at facilitating the better understanding of gene interaction (with other genes and given environments) -- now sit in the middle of the privacy conundrum simply because a variety of interests are pushing the limits on erstwhile taken for granted "informed consent" standards in both research and scientific treatment and experimentation. Yet even as the needs of R&D conflict with competing interests that range from individual privacy to public interests of access, Professor Lemmons noted how there continues to be a pressing need to guard against confounding which interests are invoked and who invokes them.
One interesting case study regarding a patent on breast cancer genetic data and testing methods in relation to it came from the work of Richard Gold of the Center for Intellectual Property Policy.
Myriad, a company which secured a patent over the testing technology as well as the genetic data, which was otherwise unchallenged in the US, ended up "in the eye of the policy storm," said Gold, when it attempted to market its tests in Canada.
While claiming the company did not choose to restrict R&D at all by making their information publicly available, its business plan included marketing a $3000 initial test for a genetic pre-disposition to breast cancer, and keep testing restricted to their Utah facility (requiring all material to be kept there). A cheaper follow up test available to the patient's other female relatives was licensed out to partner facilities.
Yet unlike the US, Canada raised several issues regarding the patent specifically with regard to the nature of the patents. For one, the scope of the patent (over the genetic data) was put into question. In what Gold characterized was also compounded by issues of "lack of trust," subsequent reactions by Myriad which included among others, cease and desist orders to those using their patented data in R&D, a confrontational stance in asserting Intellectual Property Rights and finally as a coup de gras, delivering to the Minister of Health, a set of strongly worded messages from US pharmaceutical corporations alongside a threat of US sanctions for failure to recognize Myriad's IPR in question, began a controversy which was lapped up by the media.
Ironically, the European Union reaction was not much different from Canada which also called into question the validity of the patents and ended up only recognizing a narrow right over a specific type of genetic information/mutations from Jewish populations. In the end, the rest of Myriad's patent was unenforceable in EU as well.
Clearly, the legal issue of "intellectual property rights" regimes impacts hugely on the accessibility of medical and scientific technology. Commercial interests and R&D interests (public and private) are usually united on the issue of "openness" during the R&D phase. Sharing information encourages innovation, facilitates verification and cross checks by the scientific community.
At this point, it is usually the interest of individuals and subjects of trials, patients and relatives who share common genetic material with subjects who come in conflict with "openness" paradigms. What does losing control of one's own genetic material mean for individual privacy? While R&D standards of consent are in general traditionally more stringent than actual practice in medical and health treatment interventions, doubts have always been raised about how realistic informed consent is. Biobanks either do not fully disclose the full range of applications for gathered genetic material nor do they always know beforehand what all the possible applications are.
In 2003, the World Health Organization itself expressed doubts about the effectiveness of "open blanket consent" models especially without a guarantee of anonymity.
On the other hand, at the point of invention and innovation, when issues of patentability arise, the discussion shifts somewhat and an altogether new set of issues arise. Ownership and control issues in the area of IPR have always been a problematic area and are usually the most contested site in cases of equity, justice and fairness. In the case of Myriad for instance, its insistence that it never intended to actually use its IPR on the genetic information to limit and inhibit breast cancer R&D and in fact sought to prove this by publicly making their data available to the public, its other acts have actually caused a chilling effect in the scientific community.
To be sure, different courts in different jurisdictions have decided differently. Prof. Lemmens noted how in US examples, patents got upheld in the face of claims by owners of genetic material to future commercial applications of their genes. The courts have upheld that there is no such right by the donor. Indeed a variety of legal fora and mechanisms was also acknowledged as severely limited in addressing a variety of situations that ranged from legal and ethical to medical and technological issues. In the end Prof. Lemmens noted that we need to take a second look at the promise of fixing "broken health care systems" through the speeding up of R&D and the "openness philosophy." Who is making this promise? Bringing ground breaking treatments faster to "the market" is not the same as actually bringing them to patients who need them the most.
]]>Three distinguished speakers opened year's second semi-annual Canadian Conference on National Health Law entitled "Visions," by the University of Alberta's Health and Law Institute, from November 8-10 at scenic Banff in Calgary, Canada.
The Conference covers a wide range of topics on the Canadian health care system but also brings to focus many common themes and issues that very much reflect current concerns elsewhere around the world.
All three speakers presented a critique of the Chaouli v. Quebec case, which was decided by the Canadian Supreme Court in 2005, which laid the basis for opening up private insurance provided health care purchased with public money beginning 2006.
The Chaouli case involved a 73-year-old patient who had been on a "wait list" for hip surgery for some time. Together with a private doctor, Chaouli, they challenged the law in Quebec (which is similar in over 90 percent of provinces in Canada) that prohibited physicians from engaging in double dipping (engaging in public and private practice at the same time).
In its decision, the Supreme Court of Canada held that the Quebec Health Insurance Act and the Hospital Insurance Act prohibiting private medical insurance in the face of long wait times violated the Quebec Charter of Human Rights and Freedoms. Yet while public money for privately provided health care is not exactly new in Canada, the Supreme Court's reasoning came under fire because it "bought in" to a line of reasoning that equated efficiency (eliminating wait lists) with privatization and publicly provided health care as the "root cause" of wait lists.
The discussion brought to light how the issue of "wait lists" in the Canadian health system has been used not only to promote a sense of panic over the public health system's supposed inefficiency but also to usher increasing privatization of health care in Canada.
Prof. Colleen Flood, Associate Professor of the University of Toronto Faculty of Law and Chair in Health Law and Policy, began by framing the issue as a problem of accountability and not necessarily a problem of rights, in the context of recent developments in Canadian health law and policy.
According to Prof. Flood, the Supreme Court's decision was anchored on its simplistic comparison of health care systems (which in themselves are complex). Likewise, the contentious "World Health Organization" comparison (which health care advocates have raised issues with) ranked Canada's Health system as thirtieth (France was no. 1), was also cited.
Presenting empirical evidence which in fact demonstrated how Canada's maternal mortality rate and infant mortality rates are much lower than those given higher rankings in the WHO comparison, she called attention to illogic of the Supreme Court's reasoning of blaming publicly funded health care for "wait lists," and the purported promise of privatization as the panacea of "economic efficiency."
Prof. Marie-Claude Premont cited concrete examples of the fallacy of such economic efficiency and cost effectiveness arguments. She shared the case of Quebec's decision to contract out cataract removal services, which following the logic of privatization, would end up costing less and eliminate the wait lists. From a cost of C$150 in the public health system, costs jumped up to over C$300.
Prof. Flood explained this phenomenon within "privatization of health care" as partly due to the transformation of needs that occurs. Citing examples in the US scenario where otherwise unnecessary medical procedures have been marketed as "needs," the third speaker Prof. Robert Evans also noted how the issue of frameworks "public" and "private" in the health system are also profoundly ethical issues in health provision.
Interestingly, Prof. Premont's discussion of how the term "integrated health system" -- which initially was intended to present the ideal of a fully integrated network of health care delivery in Quebec -- has been appropriated instead to mean increasing public sponsorship and spending on private health delivery.
In the Philippines, the much hyped "health reform agenda" has also been under scrutiny by feminists for this same reason. Under the purported "reform," the national government has gotten away with not budgeting a single centavo on Family Planning, pointing instead to local governments, some of whom have taken the policy to mean that it is "optional" in the scheme of health care.
Indeed, even as Canada's health system, from where we stand in a country like the Philippines, is every bit enviable and ideal, these discussions have demonstrated how even emerging discourse around "public health care" is now dominated by increasingly privatization and market based "solutions" touted as the cure all for inefficiency.
In Canada, the irony is, evidence shows that despite tax cuts, health spending has not increased substantially. Likewise, wait lists (which was the bandwagon of choice to rationalize increasing privatization), still exist. In fact, the most successful models of having addressed wait lists have come from profession-led initiatives such as the "hip replacement" services set up by doctors in Ontario, targeting such wait lists.
In the end, health advocates need to look closely at implications of health policy especially in the face of states opening up to "free market" solutions as a panacea. Such shifts not only have financial implications (where money and resources are sourced) but ultimately include issues of equity and ethics in the health professions as well as the entire health system.
]]>October is the when the annual national budget gets debated in Philippine Congress. One issue which gained media coverage this past month was Rep. Edsel Lagman's pending bill, the "Reproductive Health, Responsible Parenthood and Population Development Act of 2007."
Touting Lagman's bill as a "population management" and "population-directed" measure, many in media neglected to notice that the revised bill by Congressman Lagman also now distinctively bears the term "reproductive health" in the title.
The articles used either "family planning" or "population" even as it quoted Lagman referring to reproductive health:
All we want is to create an environment of freedom of informed choice...It is a reproductive health program without bias for artificial or natural methods. We're promoting both.
The inclusion of the term "Reproductive Health" in the title of the bill (front and center) on draft legislation in the 14th Congress signaled a significant change from the context of the 13th Congress.
In the past Congress, almost all versions of the bills related to reproductive health opted not to integrate the term in the title (except one version filed by Senator Rodolfo Biazon).
After President Gloria Macapagal Arroyo threatened to veto "policy which tried to smuggle in abortion" in her state of the nation address in 2004, pundits took it as a warning against any reproductive health bill's passage, even as the bill itself didn't carry any provision on the legalization of abortion.
By labelling "reproductive health" as a dirty word, and even warning the Anti-Poverty Commission and the National Commission on the Role of Filipino Women (NCRFW) about mentioning the term, GMA narrowed the terms for legislative engagement before the 13th Congress.
Lagman's earlier bill's was one of many versions which "avoided" reproductive health by burying the term within the bill and adopting "less suspect" titles.
Abortion, even without a legalization provision, but in relation to maternal health, and the availability of quality emergency post abortion services were usually covered up in what was seen then as the "safer" language of "Prevention and Management of Abortion and its Complications."
Lagman, who is well known in the local media as fiercely independent (despite his being in the administration's party), outspoken and someone who "did his homework" (doing his own reading and not relying only on staff) often also had a tendency to be quite intractable on his views about population, which in the past have been framed along the more traditional pre-ICPD "population control" strategies which emphasized demographic targets over, and sometimes in violation of, "free and informed choice."
When he sponsored the "Responsible Parenthood" Bill in the 13th Congress, his version came into controversy when media labelled it as the "two child policy" bill, bringing to mind the draconian Chinese one-child policy as it laid down a scheme of free education incentives exclusively for those who would limit their number of children to no more than two.
And while his bill incorporated some of the elements of key legislation supported by the Reproductive Health Advocacy Network (RHAN), RHAN continued to squarely raise issues about the policy's language and formulation and "population control" framework and frequently debated with the Congressman about the "rights based" and framework of "choice" that the policy needed.
In short, the collaboration with Lagman was at best a critical one and early on, many of us found ourselves on opposing sides of policy strategies and had disagreements with him. With networks like Philippine Legislators Committee on Population and Development (PLCPD), RHAN continued these dialogues and emphasized that the law needed to not only make reproductive health care available and accessible, but also to facilitate people's decision-making.
Before I left Manila, I had the opportunity to participate in a meeting between advocates from the Reproductive Health Advocacy Network and Representative Lagman in May, as he prepared to revise his draft bill for refilling in the newly constituted 14th Congress. In the meeting, the then newly re-elected solon (who was obviously no longer after any votes) raised what seemed to be in the past Congress, unthinkable: "Let's get back reproductive health in key aspects of the bill" (now the even the title) which literally meant facing the challenges to the frame of "reproductive health as right" head on.
He expressed that he had come around to realizing the importance of the rights framework in reproductive health, noting that the role of policy is to enhance choices and not to impose them on people. Without much prodding, he volunteered to drop all the incentive/disincentive scheme provisions of his old bill in relation to benefits and the number of children.
Lagman's decision to take challenges against "reproductive health" head on reclaims well deserved legitimacy and moral authority this side of reproductive health advocacy. While a lot of good intentions were likely invested in the process of haggling over more facially "neutral" terms (or less likely signposts to call the opposition's attention) in past debates, years later, advocates now have a clear opportunity to re-evaluate their positions. Unfortunately many in media are still stuck in the mode of framing these debates simplistically as "the church vs population control," and a lot of them have "boxed in" Congressman Lagman as a "population control" stalwart. For those in reproductive health advocacy and the Congressman, this matter ought to be a good point for more critical collaboration.
]]>Noting the link between declining abortion rates and wider contraceptive use, the story reported:
The number of abortions annually fell to under 42 million from 46 million between 1995 and 2003, with rates decreasing most significantly in Eastern Europe, said the report from the Guttmacher Institute and the World Health Organization. The number of abortions fell most in developed countries where it is legal compared to poorer countries where it is largely banned and considered unsafe, the researchers said. The report said an estimated 20 million unsafe abortions occurred in 2003, 97 percent of them in developing regions and places where the procedure is banned.
Meanwhile, the story reported that majority (that is over 35 million) of abortions take place in the developing world and that 97 percent of all unsafe abortions in poor countries.
These raise important questions in the sexual rights, abortion and reproductive health discourses today. One of course is contemplating the role of law and policy on the issue of abortion (if prohibition never worked to deter women and couples from seeking it, what is the basis for criminal sanction on consented abortion? What is it good for? What laws and policies do we need?) and second, the fact that contexts of inequality, marginalization and prohibition ultimately raise the stakes for women and their families.
Organzanizing and activism around women's right to access safe abortion has usually been structured alongside popular claims about "choice" and "privacy," which no doubt remain important bases for building both legal assertions and realization of women's reproductive choices.
This is also very true in the Philippines, where in the context of the prohibition of abortion, combined with a constitutionally vague provision declaring "equal protection of the life of the mother and the unborn," popular reproductive health discourse is often buttressed by claims of "reproductive choice," which in turn are supported by both equality, privacy and freedoms guaranteed in a constitutional "bill of rights."
While the current language of the "reproductive health bill" has no provision to challenge the illegal status on consented abortions (lacking as yet a broad enough consensus among reproductive health and family planning advocates), the bill instead targets making available (and accessible), the critical service of post abortion care, as well as a standard of humane treatment in receiving this service.
The "humane treatment" provision in post abortion care is one significant aspect of the Philippine experience on this issue. Studies have demonstrated how even as the health intervention is not exactly "illegal" and health providers are never in any danger of criminal liability (in fact the reverse is true since both professional and legal standards dictate professional duties), women coming in for the treatment (both in cases of intentional abortions or miscarriages), have been systematically subjected to maltreatment by health workers, ranging from a denial of anaesthesia, to being subjected to blaming and humiliation.
Indeed, in this case, the appeal, in order to make abortions safer and to stem rising maternal deaths and injuries from predominantly unsafe abortions, takes on language that while still based on notions of rights, is not really one of simple or straightforward "individual entitlement," but also "a general appeal to compassion," in the form of adequate care and ethical treatment.
This as expected doesn't come easy in contexts where standards of general and primary health care are not exactly ideal. As noted in the cited report: "Because providing safe abortions depends on a working health care system, experts said tackling the problem is difficult."
Given a situation of grave lack in resources (not just economic but also information and viable frameworks which impacts on public opinion and perceptions), the challenge of "rights articulation" requires a bit more than the traditionally "legally framed and individually focused" demand of a purported "state mandate," (which always presupposes a state and agencies interested in fulfilling constitutional mandates, in this case for women). Ultimately it also requires a parallel frame and equally substantial appeal to not just to the common weal, but one which resonates with the best of our moral aspirations.
]]>This fall, I began graduate studies in law and have been blogging since late September from the University of Toronto, where I was awarded a Fellowship on Reproductive and Sexual Health. The scholarship is focused on the legal and ethical issues in reproductive and sexual health. I hope to bring coverage of a range of discussions (and conference coverage) as well as contribute a variety of insights informed by the current work of experts in the field.