Abstract
In this roundtable discussion, three long-time international activists in the field of reproductive and sexual rights discuss the challenges facing the feminist women's health movement ten years after the 1994 International Conference on Population and Development in Cairo, and the 1995 Fourth World Conference on Women in Beijing. Their conversation reflects on the nature of the global context in 1994–95 and how that context has changed a decade later, especially in light of growing conservatism and the growing HIV/AIDS epidemic. They consider the successes and limitations of the Cairo agenda and the strategic importance of taking a long-term view. In particular, they emphasise the need for strengthening health systems worldwide, advocating for better and more woman-friendly use of existing resources and building broader coalitions. Much of the conversation explores points of commonality and difference between feminist groups on the one hand, and medical and family planning organisations on the other, as well as ways of utilising such venues as the World Social Forum. Points of greatest promise internationally include the growing youth movement for sexual and reproductive health and rights and the potential for opening up larger alliances around sexual and bodily rights with HIV/AIDS activists, sex workers, people living with HIV and AIDS and human rights organisations.
Résumé
Dans cette table ronde, trois militantes chevronnées dans le domaine des droits génésiques examinent les difficultés que connaît le mouvement féministe pour la santé des femmes dix ans après la Conférence internationale sur la population et le développement (Le Caire, 1994) et la Quatrième Conférence mondiale sur les femmes à (Beijing, 1995). Elles réfléchissent à la nature du contexte mondial en 1994-1995 et aux changements intervenus depuis, à la lumière du conservatisme croissant et de l'aggravation de l'épidémie de VIH/SIDA. Elles recensent les succès et les limites de l'ordre du jour du Caire et l'importance stratégique d'une perspective à long terme. Elles notent en particulier qu'il faut renforcer les systèmes de santé dans le monde, æuvrer pour mieux utiliser les ressources existantes, de manière plus adaptée aux besoins des femmes, et établir des coalitions élargies. Elles explorent les points communs et les différences entre les groupes féministes d'une part et les organisations médicales et de planification familiale de l'autre, et se demandent comment utiliser des tribunes comme le Forum social mondial. Du point de vue international, les points les plus prometteurs sont la croissance de la coalition des jeunes pour la santé et les droits génésiques, et le potentiel de créer des alliances plus vastes autour des droits sexuels et corporels avec les activistes du VIH/SIDA, les professionnels du sexe, les séropositifs et les organisations des droits de l'homme.
Resumen
En este debate de mesa redonda, tres activistas internacionales con años de experiencia en el campo de los derechos sexuales y reproductivos revisan los retos que afronta el movimiento feminista de salud diez años después de la Conferencia Internacional sobre la Población y el Desarrollo, celebrada en El Cairo en 1994, y la Cuarta Conferencia Mundial de la Mujer, celebrada en Beijing en 1995. Reflexionan sobre la naturaleza del contexto mundial en 1994-95 y su transformación una década después, especialmente en vista del creciente conservadurismo y la epidemia del VIH/SIDA. Analizan los logros y los límites de la agenda de la CIPD y la estratégica importancia de una visión a largo plazo. En particular, recalcan la necesidad de fortalecer los sistemas de salud mundialmente, abogando por un mejor uso de los recursos existentes y el desarrollo de coaliciones más amplias. Gran parte de la conversación explora los puntos en comãn y la diferencia entre los grupos feministas y las organizaciones médicas y de planificación familiar, así como las formas de utilizar vías como el Foro Social Mundial. Entre los puntos más prometedores a nivel internacional figuran la coalición de jóvenes por la salud y los derechos sexuales y reproductivos y la posibilidad de establecer mayores alianzas en torno a los derechos sexuales y corporales con los activistas en materia del VIH/SIDA, trabajadoras sexuales, personas que viven con VIH/SIDA y las organizaciones de derechos humanos.
Ros: Let's begin by setting a frame for the history and legacy of the International Conference on Population and Development's Programme of Action.Footnote† When ICPD supporters refer to the Cairo agenda, they suggest a set of commitments not only going beyond but also very different from the family planning, population control and maternal and child health programmes of the 1950s to 80s. Less optimistically, many observers (including some feminists) have seen the Cairo and Beijing documents, like so many other human rights instruments, as at best noble words, with little practical follow-up affecting real women's lives. As leaders who work closely with women's groups in many countries and regions, what is your perception about actual implementation of the Cairo agenda?
Sonia: I'd like to make two points. First, we have to look at Cairo and our achievements and flaws in the longer term, la longue durée. People get very anxious and forget that ten years in this type of process is almost nothing, particularly when you're dealing with a debate that has been going on for 200 years. Second, the problems we see with Cairo are not just related to Cairo; they're related to the whole cycle of UN social conferences in the 1990s. The global climate of the 1990s was very different from today; it was a time of big promise because of the end of the Cold War and the possibility of converting military expenditure into development, or better yet, human development. For the first time in 25 years, it was possible to discuss human rights as being universal. We forget that prior to the 1993 World Conference on Human Rights (in Vienna), the last UN conference on human rights was in 1968 (in Tehran). Another world conference on human rights was made possible in 1993 because of the climate, and now the climate has again become extremely chilly.
Ros: This wider context actually leads directly to my next question. From a more detached and slightly critical view of the Cairo and Beijing processes, the final documents were far from perfect. At the Global Roundtable in London a few months ago,Footnote* three major gaps that seemed very serious were identified. First was the failure to provide for access to safe, legal abortion as a basic human right. Second was the very limited way sexual rights were defined and not even named in those documents, even though we did make some progress. And third, the problem of resources and the failure of these documents to address the larger questions of privatisation, market forces, debt burden, militarisation, and all of the macro-economic and macro-political forces that have impeded making sexual and reproductive health and rights more than words. Do either of you want to add to or refine any of these points?
Sonia: First of all, those documents result from a political process; you don't just sit down and write them. Their ambivalences and gaps are a result of the political conditions and the balance of forces existing at the time. We didn't have the strength at that point to address abortion as a human right; we must now focus on building that strength. We are all aware of how contentious abortion rights and sexual rights are in international fora. The Programme of Action reflects what the political conditions allowed us to achieve at that point, and if you read paragraph 8.25,Footnote† it's kind of a mixed picture. You can read the positions of the political forces at play in that paragraph very clearly. This is a clear example of the nature of the Cairo document.
Is there a gap with respect to the resource dimension or macro-economics? I wouldn't say so. Relevant recommendations in this domain were addressed at the World Summit for Social Development in Copenhagen (1995), in Beijing, in Cairo, but once again, the problem is not that these issues aren't in the document; the problem is that the issues have not been resolved in reality. The documents went as far as they could at the time they were created, and they are better than the political reality today.
Adrienne: I agree with Sonia's analysis. We must also look at the scope for practical action in today's world, having recognised that the context is not even as good as it was when the original documents were adopted. With regard to abortion, I'm not sure strategically that we can pursue it as a human right, in our global advocacy at least. The strategy adopted since Cairo – abortion as a public health issue – has been effective in forging WHO policy and technical guidance, and in various inter-governmental negotiations, where asserting a woman's right to abortion would not have worked. At the same time, all of us must take every opportunity, especially at country level, but even at global level, to bring the women's rights dimension into conversation and strategy, where possible. Of course, this is a strategic decision in each country.
Second, on sexual rights, in the political environments that we now face, both global and context-specific, we need to work on clarifying the concepts, and building the broadest possible support for language that could, with a lot of effort, be accepted in the global policy arena. Our biggest challenge is to get leading, sympathetic world governments to move forward on the recognition of sexual rights. In a way, the Brazilian government has set a marker with its 2003 resolution to the UN Human Rights Commission.Footnote* But the women's movement, together with the other constituencies (for example, lesbian, gay, bisexual and transgender (LGBT) groups and sex workers) that have the strongest vested interest, must think about how much we are able and willing to compromise, from our different perspectives, for the sake of progress in the global policy arena. We faced that challenge before Cairo with respect to reproductive rights, and I believe we can and should be doing the same with sexual rights.
Third, on resources, money is rarely the core problem. There's a lot of money out there under different labels which is badly used. So while the macro-economic picture is critically important, I also think that we should focus on re-programming the resources that have already been allocated so that they benefit the people we are most concerned about.
Sonia: Brazil is a good example. In comparison with other developing countries, we have a huge health budget; yet it is still inadequate in the face of existing needs. Within that larger context, the resources for women's health and reproductive health are, and have historically been, much more limited than those devoted to HIV/AIDS. This budget imbalance between what is provided for reproductive health (elements of the Cairo agenda) and what is provided for HIV/AIDS can be explained by the sense of crisis. HIV/AIDS has much more capacity to mobilise the popular imagination, policymakers, providers, the media, civil society itself, than women's health does, which is viewed as “business as usual,” not requiring significant technological or financial investment.
Ros: You've actually moved us toward my next question: What are the major obstacles holding us back, and what will be the most effective ways to surmount or transform these obstacles? Adrienne, you've pinpointed the misuse or distorted use of existing resources. Sonia, you're beginning to get at something much more elusive but critically important, and that is the question of popular perception and imagination, or what issues grab policymakers, media, opinion makers and the public.
Sonia: In Brazil, for example, we face a very mixed picture. As you know, Brazil was ten years ahead of Cairo in the 1980s and a major leader in Cairo and afterwards on sexual rights. But since 2003, the Brazilian public has been discussing family planning in the most conventional neo-Malthusian way. What is grabbing society's imagination is the connection between poverty and the number of children poor women have. It's been very difficult for the feminists and even progressive demographers to shift that conversation in a different direction. It's not easy to convince the public and opinion makers that average fertility is already very low, and that the percentage of women who have more than three children is just 6% of women between 14 and 49. People see violence, they see beggars and homeless people living on the street and they connect that with women having too many children. The public do not yet fully understand the rights-based approach of Cairo. As an illustration, to address the “need for population control”, some parliamentarians and policymakers are even urging a constitutional revision to authorise sterilisation (in the poorer sectors). It is very alarming.
On the bright side, we are starting to see a growing interest in the concepts of reproductive rights and sexual rights, terms which high-level policymakers are now using. More and more, journalists are asking feminists and LGBT activists about sexual and reproductive rights. The abortion debate has gained great visibility as a result of feminist activism on the subject; in 2004, the Minister of Women's Policies announced the creation of a working group to review punitive legislation. Conservative attacks on sexual rights with regard to LGBT communities have received great attention in the press, and two major legislative battles have just been won. State-level legislation restricting benefits for same-sex partners of public servants was defeated, as was a provision aimed at creating a government-funded programme to “rehabilitate” LGBT people. So this is all happening at the same time that we have this very tired debate about having fewer children as an antidote to poverty.
Adrienne: I would reinforce your point because we see the same phenomenon in the North: a resurgence of neo-Malthusian actors who were there pre-Cairo. And this phenomenon ten years after Cairo, this traditional demographic focus, goes hand in hand with the conviction among some actors that the Cairo reproductive health and rights agenda is too expensive and too complicated to implement, so why don't we go back to what we know and what we think worked earlier – in other words, vertical family planning. What they seem not to realise is that both the political and the demographic dynamics have changed since the 1990s. We now have the largest generation ever of people under 19 years of age who are, or are soon to become, sexually active.
For the first two to three decades of population policy, the focus was on women in their late 20s who had three or four children and were willing or could be persuaded to be sterilised. Most population growth will now come from much younger people. Where there are high prevalences of HIV and/or STIs, most modern contraceptive methods leave young people at risk of infection. In my view, we must offer young people the full range of contraceptive choices, while being very clear about STI and HIV risk, and ensure full access to condoms backed up by emergency contraception. The population field has never promoted condoms, however, is only recently taking up emergency contraception and has shied away from safe abortion. So, there is a dissonance that is worse than regrettable; it has led to enormous tragedy.
Of course, it's important to recognise, as Cairo did, that family planning is a crucial part of reproductive health services, and an essential right. Contraceptive prevalence has risen dramatically in the past 10–20 years, and that is to be celebrated, but there are millions of people around the world who still lack access to contraception. At the same time, some programmes are regressing to population control strategies. Such approaches foment resentment and fear among both women and men and in the end fail to achieve the fertility reduction they aim for.
Sonia: I agree with Adrienne. The fundamentalists' attack on Cairo, particularly backed up by pressure from the Bush administration, gives neo-Malthusians an opportunity to say: “Well, you see, it's so complicated. It raises controversy, so let's get back to family planning.” Even the Bush administration, when it speaks out virulently in the global arena against abortions and reproductive rights, still gives some money, if not enough, to family planning and post-abortion care. What is being deleted from all sides is the feminist agenda, because of the big imbalance of power between the feminist movement and our allies on one side, and the other actors in this field.
Ros: So far, gender has not come across in all of what you've said. If the HIV/AIDS crisis grabs people, Sonia, why are the unnecessary deaths of 500,000 women a year from maternal causes not a crisis in the same way? Why do the murders of hundreds of women in Ciudad Juarez not grab people? Even with HIV/AIDS, the attention of media and politicians is not at all focused on black women aged 25–44 in the United States, whose risk of dying of AIDS is 13 times higher than that of their white counterparts. What is going on?
Sonia: One main problem, as I see it, is the way policymakers and epidemiologists view scale. They compare the number of women who die or have died because of HIV/AIDS in Brazil with the number of maternal deaths, and they say that maternal mortality is not a problem on the same level of magnitude. This is one of the reasons why it took six years, from 1997 to 2003, to institute a compulsory registration system for maternal deaths in Brazil in the national health surveillance system.
Ros: But is capturing the popular and political imagination really a matter of scale? Many more women in Brazil die of cervical cancer (or of breast cancer in the US) than die of AIDS, but where is the outcry?
Adrienne: It's true that epidemiologists weight numbers heavily. But issues like maternal death and lifelong maternal morbidity, or the death rates and lifelong consequences of violence against women, are still on the side burner because of the imbalance of power between men and women. Although women have mobilised in virtually every country, we are still very often marginalised when it comes to budgets, laws and policymaking.
Sonia: We feminists are very small in number. When even one of us moves from civil society to work in government, a big hole is left behind. So there's a problem of our human and institutional capacity that is also at play.
Ros: But vibrant, powerful, effective social movements have not been based primarily on numbers. One can think of many historical examples of movements that have prevailed without being enormous. Feminist leaders and organisations are only as effective and strong as the movements that stand behind them.
Sonia: I think that one problem is that we are kind of a guerilla movement. As feminists we are not many; we are very smart and can be very strategic, but we are small in comparison not just to institutions but also to other social movements. I can give you an example from Brazil, but it applies anywhere. If you compare the ability of the HIV/AIDS movement and the feminist movement in Brazil to make policy change, the big difference is that the feminists operate at the strategic level, trying to have experts in place, being very intelligent, with good policy formulation…but we don't have people screaming in the streets when things don't work. If the system is not working, HIV activists go to the streets; they have that capability of mobilising people.
Ros: Well, in the US more than a million people, mostly women and girls, marched in the streets of Washington DC last year for reproductive rights. An amazing moment, yet it seems to have disappeared from public memory. One important tool in spreading the word and mobilising people has been the internet, and it is being used more frequently to get groups of people to meet physically and work towards common goals. What else can we do to build a younger, more powerful movement for the coming decade that can sustain such actions? What do you think will be the most successful strategy for building that kind of movement?
Sonia: One challenge is that there's a new generation in the world. These girls (and boys) have grown up in conditions that differ widely from the conditions in which we became adult women. Our analyses and discourse on gender and reproductive and sexual rights don't always capture their imagination. My own daughter is often quite dissatisfied with the victimising tone of feminist analysis. Another challenge is the ability to make health systems work and to talk about them in a manner that responds to the needs and desires of people. What the intellectuals in the Brazilian HIV/AIDS movement demand is convergent with what people need on the ground. Sometimes, however, the feminist agenda is not exactly in line with what ordinary women want. One example is sterilisation. Many women want it as an option, but many intellectuals are critical of sterilisation. On the other hand, sometimes we do very well, as in the case of ensuring that women eligible under the law have access to safe abortion services, or as Uruguayan feminists did last spring when they pursued legal abortion through a broad reproductive health bill. Their public education efforts captured the imagination of many people, both younger and older. These success stories should be examined more closely for critical insights on how to move forward.
March for Women's Lives, Washington DC, USA, April 2004
Adrienne: Regarding revitalisation, I don't actually think we've lost steam. Those of us who went into Cairo are ten years older now, we've been doing a lot of hard work in our own organisations and professions, and we're trying to carry the feminist movement agenda forward, often in our so-called “extra” time. What is revitalising me, and certainly should be part of the engine driving the politics of implementing the Cairo agenda, is the youth movement, in particular for their own sexual rights and health. Both young men and women, who at the same time as taking action and building networks that are coalescing into a movement, are changing how they themselves relate to each other and work together. While I want to recognise that it was largely women who initiated and brought the Cairo agreement to fruition – and until recently it was also primarily women who defended those agreements – what we've seen, even at the UN, is more and more of the youth, male and female, coming in to defend and take ownership of an agreement they realise is in their own interest.
In addition to the youth, to succeed and maintain our movement's legitimacy, credibility, and political power, we must do more to draw in the mainstream human rights community as our ally. They are still mainly preoccupied with civil and political liberties at the global level, with important exceptions such as Human Rights Watch and Amnesty International, and rarely engage with women, youth, sexual minorities and others at the country level. I also wonder why the wider women's movement is hardly working on sexual and reproductive health and rights in some countries and globally. Is it just a division of labour because we have so few resources to cover an enormous agenda?
Ros: If you raise the issue of HIV/AIDS, it really depends on which women's movement you're talking about. Women of colour organisations in the US are tremendously mobilised around HIV/AIDS because their communities are particularly at risk. They know HIV/AIDS is linked, for example, to prisons, because when men go into prison, they get infected and come back into the communities. Also, the rapidly growing number of incarcerated women get virtually no sexual or reproductive health care.
Adrienne: I agree, but my concern is that we must somehow mobilise greater interaction and solidarity across the many different elements of the women's movement, precisely to support each other. For example, activist women who are trying to work on behalf of women in HIV/AIDS movements are too often drowned out by other segments of those movements, even in sub-Saharan Africa where girls and young women are infected at much higher rates than men their age. So what can we do more broadly to support the struggle of HIV activists such as these? And how can they help us to work on changing global health policies and resource allocations?
Sonia: Certainly there are tensions. In Brazil, relations between many feminists, “ordinary” women, gay men, transvestites and sex workers, who are all major actors in the Brazilian HIV/AIDS scene, have not always been easy. This is true not just because of power differentials, but also because both feminists and the wider women's movement have difficulties dealing with sex workers and the issue of commercial sex. More recently, very productive dialogues on sexual rights have been evolving among feminists, LGBT groups and sex workers, but not everywhere, and often the greatest obstacle is the conversation between feminists and sex workers (of all genders). There's an ideological difference at play between and among women themselves. But the HIV/AIDS movement in Brazil has been able, with some disparities, to encompass a wide range of voices and positions, and HIV-positive women are gaining a voice and public space.
Adrienne: Exactly. Across the many elements of women's movements, as well as other social justice movements, we are not creating enough dialogue and engagement with each other such that we could build a much stronger political power base.
Ros: This really leads us to the issue of coalition building. Aren't you saying that if we could figure out good tactics for dialogue, the combination of the HIV/AIDS movement and the feminist sexual and reproductive health and rights movement, along with sex workers, LGBT groups and human rights groups, would be a very powerful political force?
Sonia: The creation of the concept of sexual rights is something we should value as a platform for conversation that may help drive coalition building. This is another conversation we have too rarely. While the definition of sexual rights in Cairo has limitations, we need to value it. It was the feminist community working at the UN level that crafted this incredible concept of sexual rights that goes beyond identity politics, allowing us to address issues of violence, race and disease prevention and at the same time issues of pleasure, autonomy and self-determination. Before this concept of sexual rights, we were talking basically identity politics, but that is not a lens through which we can effectively address or resolve political differences. We cannot continue to speak only among women.
Ros: The concept of sexual rights would never have been imagined without the LGBT movement, as well as the HIV/AIDS epidemic, which first made public discussion of sexuality unavoidable and then made it possible to speak about sexual rights. At the same time, it's also true that women's groups and feminist thinking were responsible for moving the sexual rights agenda towards a broader, more inclusive human rights frame.
Sonia: We did invent the sexual rights frame, but at the ground level, our rhetoric and activism are still mainly informed by identity politics. Sexual rights is the open platform to embrace everybody, but in daily political practice, we're still acting on the basis of our separate identities as (white) women, women of colour, sexual minorities, racial-ethnic minorities, which narrows our potential reach.
Adrienne: That's one reason I've been so energised by organised youth; those I know don't segment themselves by any identity except age. Rather, they take deliberate steps to be inclusive. In this way they may have the potential to reach more varied constituencies and to draw them in as they build their movements. I hope we can support and encourage their efforts to do this earlier and better than many of us have done.
Sonia: I agree with you, but it's not just a matter of gathering the different. You can gather people together, as in the World Social Forum (WSF),Footnote* without there being a genuine dialogue. We have to bridge differences. What is very interesting about the young people we met in London and elsewhere is that they have huge differences, yet they are able to weave their concerns and perspectives together to move beyond just “identities”.
Ros: The crucial thing here is that “multiculturalism” as an approach to difference doesn't get us to transversal politics where people really listen to each other across differences and figure out together what those differences mean for building a coalition. That's something a lot of us who have been working on Cairo haven't been doing actively enough. We might look at the Rainbow Planet Coalition in South AsiaFootnote* as a model of collaboration among women's groups, people living with AIDS, HIV/AIDS activists and sex workers.
Sonia: Yes, but we have to recognise that these conversations are just starting. Here we have a major problem when you get back to policy level; there's a huge tension and gap between the timeframe of policymaking, with many emergencies all the time, and the longer time required for building coalitions and bridges.
Ros: Another issue is that some of us have tended to operate in certain defined UN spaces. Should we attempt to have a stronger presence in alternative political spaces such as the WSF?
Sonia: The WSF is certainly a space where you are able to interact and to raise the agenda of sexual and reproductive health and rights, to make it visible and create awareness about how it links to other agendas. I would say the WSF works as a kind of marketplace for social advocates where we can publicise sexual and reproductive health and rights. This is important to ensure that WSF actors fully understand what the Bush war against women, young people and sexual rights advocates means, for example, and how it links to the neoconservative agenda more broadly. But whether the WSF can be a viable space for building cross-sectoral alliances remains to be seen.
Ros: In addition to alliances through the WSF, youth coalitions and other groups interested in sexual rights and HIV/AIDS, what about the more mainstream reproductive health and medical organisations, the kind of organisations that we were trying to interact with at the Global Roundtable?
Adrienne: First of all, I hate to label and to be labelled, but I would distinguish between the broader medical and public health community and the family planning community. One of the most tenacious commitments of family planning/population groups pre-Cairo was to avoid medicalising contraceptive services. In Asia, for example, they favoured services that could be delivered by a specifically trained family planning worker who didn't have a medical background. In sub-Saharan Africa, family planning was often provided in maternal and child health services, but by mid-level workers not trained to address the many dimensions of reproductive health. By comparison, the Cairo agenda requires a functioning health sector. And it's precisely the health sector that the family planning and population movement didn't want to engage with except when absolutely necessary, in the case of complications and emergencies.
Partly as a result of this history of division between health and family planning, a substantial segment of health sector leaders I have met outside the US were narrowly trained in family planning, and are not at all persuaded that reproductive health should have priority. So we commonly see lack of investment in obstetric care, diagnosis and treatment of reproductive cancers, and diagnosis, testing and treatment for STIs in women. The longstanding family planning/population community – and here I'm talking about groups like the USAID population programme, or Washington DC lobbyists – appreciates and provides rhetorical support for the long-term vision of Cairo, specifically reproductive health, yet when you look at where their resources are going, it is family planning. They feel compelled to endorse the reproductive health agenda of Cairo but they also feel free to say that Cairo is too expensive and too complicated, so let's just do what we know how to do. The divide is now complicated with HIV/AIDS; we must promote and support universal use of condoms, but this is a technology the family planning field has said was not effective enough for contraception since the IUD and pill came on the scene.
Sonia: I agree with Adrienne's analysis in terms of the global level, particularly in the US, but there's a lot of variation across contexts. In the case of Brazil, our relationship with the medical community and public health professionals was a key element in the construction of the whole women's health agenda. The same applies to HIV/AIDS policies. Because the women's health agenda was about reconstructing the health system, we have always had a kind of alliance with both health professionals and policymakers. But there remains an unresolved tension. Most public health advocates and managers tend to emphasise a universalist concept of collective health and resist any specific health agenda. They may rely on macroeconomics or scarcity of resources as their main argument (World Bank economists), or they may emphasise class dimensions and inequality (Brazilian public health advocates), but they often resist focusing on the needs and demands of specific social groups, such as women and sexual minorities.
Adrienne: The same resistance to a gender approach is true in some recent global initiatives and donor approaches to overall development strategies like the Poverty Reduction Strategy Papers of the World Bank, funding modalities like sector-wide approaches and even major reviews of health challenges such as the report of the Commission on Macroeconomics and Health.Footnote* Yet, where health systems are the weakest, and by weak I mean lacking money and also trained staff, the bulk of the most disadvantaged, or sickest, most incapacitated people are women and children. To change this, we must not only strengthen primary care, but also create an effective referral system to functioning secondary level care. If you undertake this strengthening, focusing initially on women's needs, you will at the same time build a health system capacity that ultimately serves everybody. A challenge that the movement faces is to convince people that reproductive health is not the demand of a special interest group but of the majority, especially if you include healthy babies and young children in reproductive health.
Sonia: Two things are missing in this discussion. One, looking to the Brazilian experience, which would also apply to other Latin American countries at least, is that most components of reproductive health or women's health are perceived and performed by the professionals in the health system as something secondary. This is because simple or routine and repetitive health measures are not as highly valued by many health professionals as high-tech ones. The director of one of the first clinics to provide abortions in Recife says that it's very difficult to introduce manual vacuum aspiration, for example, because the doctors tell her it is poor technology for poor countries.
The second missing element is that in the last 20 years, at least in Latin America, some obstetrician–gynaecologists have been our major allies on the very critical issue of abortion, committed and outspoken leaders such as Dr Anibal Faãndes and Dr José Barzelatto in Latin America, and Dr Mahmoud Fathalla in Egypt. Earlier, you had a handful of doctors, whereas now there are many in Brazil, Uruguay, Argentina, Mexico, who are really engaged in the conversation on safe, legal abortion. This is a major achievement we should not forget.
Ros: Good points. Before we close, I want to note that one part of the world we haven't talked about is Central and Eastern Europe. There weren't many women from that region at Cairo, and although there were more at Beijing, both documents are based on a North–South paradigm, which Central and Eastern Europe do not fit into very well. Often, their governments do not identify themselves with the developing world, which can be a huge barrier to implementation of Cairo and Beijing. Activists in that part of the world have had to work in unique ways when lobbying their governments.Footnote† So let's continue to broaden this conversation and make it more inclusive.
Now, to close, I want to take us back to questions of strategy. Given the state of health systems and the divisions among women's groups, family planning groups and health establishments, could you each try to map a few strategic priorities for the women's movement going forward?
Sonia: The many layers we've addressed suggest an array of challenges not easy to summarise. The international women's sexual and reproductive health and rights movement needs to understand and plan for the fact that our agenda is long term and that its translation into concrete policies and effective rights takes persistence beyond UN documents and demographic and epidemiological evidence. It is a matter of struggle, of political economy involving powerful forces that are often not in our control. With this in mind, there are at least three major tasks at hand. The first is to systematically connect microanalysis and processes with macro-trends in financial and trade policies as they affect governance at large and the structure of health systems in particular. An example would be developing a much more rigorous analysis of the impact on sexual and reproductive health and rights, in different contexts, of privatisation of health services and of trade agreements within the World Trade Organization (WTO), particularly GATS.Footnote*
The second area is partnerships and alliances. Potential partners and allies will differ according to context. For instance, in Brazil the demographic community has been a critical ally of feminists, but this is not true everywhere. At the global level, our conversation indicates that dialogue with the HIV/AIDS, LGBT and human rights communities is a priority, along with a range of actors involved in the World Social Forum. And while many tensions and misunderstandings persist among the feminist movement, family planners and the medical community, we must continue to work with these groups.
This leads me to the biggest challenge: we cannot move productively in all these areas with our current woman-power. For that reason, a strategic and urgent effort is required to ensure an infusion of new energy from diverse groups of all ages, but especially the younger generation – women, men and other gender identities – in our debates and organisations. This renewal will take different forms in different settings, but it is not something that we can keep delaying as if the movement will renovate itself “naturally”.
Adrienne: To achieve access to safe, legal abortion, realisation of sexual rights and provision of sexuality education and health services for the young people already born, we must hone our strategies even further. First of all, we must help HIV/AIDS policymakers see that prevention in girls and women requires full financing and implementation of the Cairo and Beijing agendas. We talked earlier of capturing the imagination and attention of the public and policymakers. We have a lot of work to do to convince HIV/AIDS leaders to invest their resources in expanding access to and strengthening condom provision, sexual and reproductive health services and sexuality education that promotes gender equality, women's empowerment and human rights.
Second, we need to heighten the movement's strategic investment in global processes and frameworks, and in today's world that means the Millennium Development Goals (MDGs) and Declaration. We have to take time to comment thoughtfully on documents, attend technical meetings, lobby governments and all the rest. We know that, perhaps more than any other UN conference in the 1990s, Cairo provides the foundation for the MDGs; just look at Cairo's chapter titles! These goals are now the world's shared destination, and Cairo is the most direct route to achieving them. People worry that Cairo's reproductive health goal is missing from the MDGs, but I say that if we get the global plan to achieve the MDGs right, sexual and reproductive health and rights will be the backbone.
Finally, and we've touched on this throughout, we need to deepen our commitment to each other and to those we represent, while at the same time, as Sonia says, building new allies and rejuvenating our own movement. Feminists, demographers, family planners, health service providers, AIDS activists, human rights advocates and youth leaders all want fewer women dying and suffering from complications of pregnancy, HIV/AIDS and violence. We all want kids to grow into healthy, happy adults. We all know that sexuality and power lie at the core of both pleasure and great pain. In October 2004, hundreds of heads of government and other global actors signed a World Leaders' Statement supporting ICPD on its tenth anniversary and calling for full funding and prioritisation of this historic action plan.Footnote† We need to help them make good on their commitment.
Ros: I want to go back to Sonia's point about the importance of realising sexual and reproductive health and rights beyond UN documents. It can move us, not to a conclusion, but to new points of departure. One of these, which we touched on earlier but bears further comment, is that of broader coalitions. If we think of the powerful, often pernicious forces driving today's world – neoliberal economic regimes, militarism and imperialist interventions, religious fundamentalisms – it's clear that all involve massive violations of sexual and reproductive rights. The positive side of these assaults (if there is one) is that they create new oppositional constituencies. I'm thinking of health care advocates, providers and consumers who oppose privatisation and shrinkage of public services; human rights and anti-war groups outraged by sexual torture in Iraq, Guantánamo and elsewhere, and the doctrine of imperial impunity that sanctioned it; and the sexual minorities, sex workers, youth, married women and others who suffer the greatest indignities from fundamentalist definitions of purity, manhood, womanhood and reproduction. All these constituencies are important allies in the struggle for the right to bodily integrity. But what this means is we can no longer see women's bodies as the exclusive site of sexual and reproductive abuses, or women as the exclusive claimants of sexual and reproductive rights. We need to reaffirm Cairo and Beijing for sure, but we also need to move beyond them.
Acknowledgments
Many thanks to Jennifer Kidwell of the International Women's Health Coalition for substantial contributions to transcribing and editing this conversation. We are also grateful for stimulating and insightful reviews and comments by Asha George, Frances Kissling and Wanda Nowicka, which inform this paper.
Notes
* “Our movement” refers to the feminists who helped generate the outcomes of many UN agreements during the 1990s, especially the 1994 International Conference on Population and Development (ICPD) in Cairo, and the 1995 Fourth World Conference on Women (FWCW) in Beijing, as well as many others who have defended those goals and are working in many and various ways to achieve them.
† The ICPD was a landmark meeting at which 179 governments agreed to a comprehensive Programme of Action to ensure universal access to reproductive health, uphold fundamental human rights, alleviate poverty, secure gender equality and protect the environment. At the FWCW the following year, 179 governments agreed to a Platform for Action to secure women's human rights and to eliminate discrimination and violence from women's public and private lives. Hereafter, “Cairo” refers to the ICPD or the ICPD Programme of Action, and “Beijing” to the FWCW or the FWCW Platform for Action.
* The Countdown 2015 Global Roundtable was an NGO-led international meeting marking ICPD at 10, 30 August–3 September 2004, London.
† “In no case should abortion be promoted as a method of family planning. All governments and relevant intergovernmental and non-governmental organizations are urged to strengthen their commitment to women's health, to deal with the health impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family planning services. Prevention of unwanted pregnancies must always be given the highest priority and every attempt should be made to eliminate the need for abortion. Women who have unwanted pregnancies should have ready access to reliable information and compassionate counselling. Any measures or changes related to abortion within the health system can only be determined at the national or local level according to the national legislative process. In circumstances where abortion is not against the law, such abortion should be safe. In all cases women should have access to quality services for the management of complications arising from abortion. Post-abortion counselling, education and family planning services should be offered promptly which will also help to avoid repeat abortions.”
* This resolution is the first-ever UN resolution with a primary focus on human rights and sexual orientation, and would have condemned countries that discriminate based on sexual orientation.
* According to its Charter of Principles: “The World Social Forum is not an organisation, not a united front platform, but ‘…an open meeting place for reflective thinking, democratic debate of ideas, formulation of proposals, free exchange of experiences and inter-linking for effective action, by groups and movements of civil society that are opposed to neo-liberalism and to domination of the world by capital and any form of imperialism, and are committed to building a society centred on the human person.’”
* A coalition of groups working on the rights of sex workers and sexual minorities, under the rubrics of sexuality, HIV/AIDS and minority status.
* A WHO commission examining the interrelations among investments in health, economic growth and poverty reduction. At: ⟨www.cmhealth.org⟩.
† The authors would like to acknowledge the input of Wanda Nowicka.
* The General Agreement on Trade in Services is an international trade agreement that was adopted as part of the Uruguay Round of trade negotiations and came into force on 1 January 1995, with the advent of the WTO. “The aim of the GATS is to gradually remove all barriers to trade in services. The agreement covers services as diverse as banking, education, health care, rubbish collection, tourism or transport.” Its details continue to be under negotiation. See ⟨www.gatswatch.org⟩ and ⟨http://tsdb.wto.org/wto/public.nsf⟩.
† At: ⟨www.icpdleadersstatement.net⟩.