Ms. Germain, President of IWHC since April 1, 1998, has worked for 25 years to promote women's opportunities and reproductive health and rights in Southern countries. She joined the staff of the International Women's Health Coalition in 1985 as Vice President and has been the architect of the organization's programs. Prior to joining IWHC, Ms. Germain worked for 14 years at the Ford Foundation, where she was the first woman to serve as a Resident Representative. In this capacity, she spent four years in Bangladesh directing a grants program in agriculture, rural employment, international economics, women's rights, arts and culture, and reproductive health. She also worked for two years as Staff Associate at the Population Council.
Among her many distinctions, Ms. Germain serves on Human Rights Watch/Asia, the Advisory Committee of the Women's Rights Project of Human Rights Watch, and the editorial board of Reproductive Health Matters. She is a member of the Council on Foreign Relations and an advisor to the Swedish International Development Cooperation Agency (Sida). Ms. Germain was a member of the official United States delegations to the International Conference on Population and Development in Cairo (1994) and the Fourth World Conference on Women in Beijing (1995). She is an alumna of Wellesley College and the University of California, Berkeley, where she earned degrees in sociology and demography.
Michael Teitelbaum has given you an analysis of the historical philosophical debates about whether or not there is a population problem and how to define it -- a debate not resolved to this day. A similar intense debate about policy has gone on for the last 40 years. There are those who say that population growth will take care of itself--as happened in the industrialized world. On the other side are those who argue for intervention on a high priority basis. In the late 1950's interventionists gained the upper hand in national and international policy debates. Led by U.S. scholars, people and agencies with both political and financial clout created population professionals and an international population "field" -- policies, research and programs -- to control population growth in the so-called "developing" countries of Asia, Africa and Latin America.
The objective was to reduce high fertility. The means was family planning programs to deliver modern contraceptives to the largest possible number of married women of reproductive age -- in essence, a technological fix to what is, in fact, one of the most intimate, and intricate, aspects of individual and social life. Sexual behavior and gender power imbalances were not part of the solution -- they were considered to be politically or culturally sensitive. Though these narrowly construed population programs and policies were deeply flawed in the view of many -- including myself -- they have been important contributors to the unprecedented, worldwide decline in fertility in the last two decades.
Debate once again rages -- this time about whether fertility decline is going too far. Ben Wattenburg, Nicholas Eberstadt and others currently argue that we will increasingly face both personal and social consequences of enormous import because of the "aging of populations." At the same time, demographers and proponents of population control point out -- rightly -- that fertility has not yet reached replacement level -- in some countries fertility is far from replacement level. As important, they point out that the world's population will at least double even if all couples have only two or fewer children from today onward. This is due largely to the phenomenon demographers call "population momentum" -- that is, continued growth generated by the unprecedented numbers of young people already born who will enter their sexually active years in coming decades.
Until 1994, those determined to minimize this future growth equated population policy with family planning. In 1994, at the International Conference on Population and Development --the ICPD -- in Cairo, the paradigm for population policy shifted dramatically. The world’s governments -- supported, prodded and cajoled by non-government actors, especially women's organizations -- agreed on a new approach to population policy centered on individuals' rights and well being, within broader strategies for poverty alleviation and sustainable development. In this paradigm, contraceptive services are to be provided as part of more comprehensive, good quality reproductive health services. At the same time, the paradigm requires investments to expand women's life choices, achieve gender equality, and provide sexual and reproductive health information and services to adolescents.
Since the Cairo conference, debate has flourished about whether or not the ICPD programme of action constitutes "population policy." The negative view is that the ICPD agreements contain no population projections, no demographic analyses, and no specific goals for contraceptive acceptance or fertility reduction. Where, therefore, is the "population policy"? The positive view is that the Cairo agenda constitutes population policy in the broadest sense. It supports reproductive freedom, and it promotes other policies to generate conditions conducive to smaller family size. In demographic terms, the Cairo agenda both encourages fertility control and also addresses the determinants of high fertility.
The ICPD agenda looks to broad "social engineering," rather than birth control propaganda or incentive schemes, to counter what Judith Blake called the "coercive pronatalism" of everyday life. That is, the ICPD agenda would create socio-economic conditions in which it makes sense for individuals to have two or fewer children. It requires simultaneous and synergistic commitments by health and development agencies. Health agencies would be responsible for ensuring that individuals and couples can achieve their reproductive intentions in a healthful manner. Among other desirable outcomes, these sexual and reproductive health investments would reduce or eliminate unwanted fertility. At the same time, agencies concerned with education, labor, agriculture and other social development sectors would emphasize gender equality and poverty alleviation. Among other benefits these investments tend to reduce desired family size -- i.e. wanted fertility -- and to slow population momentum. The role of population professionals and agencies in this broader development arena is to undertake research and advocate for broad policy changes.
Let's examine the case of Bangladesh, with 122 million people, the ninth most populous country on earth and one of the ten poorest.
After 20-some years of an intensive, vertical family planning program:
From a family planning program perspective, Bangladesh is a "success" story. But is the current, "population policy" -- emphasizing contraceptive delivery to married women --the one to maintain in the next two decades? Consider the following facts:
In sum, Bangladesh has a very youthful population, extremely high death and illness related to pregnancy, poor health infrastructure, and growing disease. What is the appropriate policy response?
Based on a commitment to health and justice, and to achievement of population stabilization, the government of Bangladesh, together with almost all of the major donors and international agencies active in Bangladesh, have framed a national health and population sector strategy, which takes the ICPD agenda as its starting point and refines it to suit Bangladesh conditions. I have been working on behalf of the Swedish government in the consortium to design the five-year program and financial package to implement this national strategy. Among the many lessons from our experience so far is that major shifts are required in the demographic -- or, more broadly -- the population research agenda. Bangladesh has one of the largest bodies of demographic and population studies of any country. While helpful, that literature falls far short of what is needed to design and implement a health and population strategy based on the ICPD agenda.
Central to this agenda is the concept of sexual and reproductive health and rights, a concept that stands in stark contrast to the earlier paradigm which equated population policy to family planning services. The reproductive health concept creates a new lens, filtered by sex and gender, through which to scrutinize the assumptions, research questions, program assessments and policy analyses of the population profession. Our experience in Bangladesh leads us to posit a new framework of analysis and a research agenda for a post-Cairo demography. That agenda would give higher prominence to the social context of sexual, marital, and reproductive behavior across all three elements of John Bongaarts' framework for population stabilization -- preventing unwanted pregnancy, reducing desired family size, and slowing demographic momentum. It includes those conditions that contribute to both the "accidental" and the "deliberate" fertility and health outcomes with which we are concerned:
Current demographic survey tools are not up to this task: demographic and health surveys in Bangladesh as elsewhere, for example, do not survey the young and unmarried; nor have they analyzed and published data on abortion, safe or unsafe; they do not assess the social context of decision-making. Nonetheless, these surveys have been the primary tools used for population program planning. With some very important exceptions, such as Mead Cain's work on patriarchy, and recent analyses of the interaction between family planning and women's empowerment by Ruth Simmons, Sidney Schuler and Sadjeda Amin, most demographic research in Bangladesh has been narrowly focussed on contraceptive acceptance and use, and on fertility reduction.
At least five research areas require emphasis, not only in Bangladesh but worldwide, to support implementation of the ICPD agenda.
The first is the situation of young people, their life choices, including, but not limited to their sexual and reproductive desires and behavior. About 47% of the population of Bangladesh is currently less than 15 years old. By 2010, Bangladesh will have approximately 31 million people aged 10-19. This "demographic imperative" requires a major shift in our understanding of the "clients" to be served. Without neglecting traditional family planning program clients -- married women of reproductive age -- research is needed to inform action directed toward educating and influencing young people about sexuality, gender relations, mutual consent and respect in sexual activity and union formation, and the means to prevent both pregnancy and disease. Methodologically, data should be aggregated in one or two year cohorts (e.g., ages 15-16, 17-18, 19) not the usual five years (i.e., 15-19).
Second is the significance of both sex and gender which underlie reproductive and health seeking behavior. Neither of these has yet been explored in detail in Bangladesh -- we have only the crudest understanding of the cultural meanings attached to sexuality, the power relations between women and men in sexual and marital relations, or the negotiation of fertility decisions.
Third is the decision-making environment. The Cairo agenda mandates social, economic and political initiatives at the national level to create an enabling environment for the exercise of sexual and reproductive health and rights, and for population stabilization. The health and population sector strategy work in Bangladesh recognizes that changes have occurred, for example, in the status of women in the last 20 years. Quantitative and also qualitative research, like that by Simmons, is needed to document these changes. Their multiple benefits, as well as their costs, need to be evaluated along with additional means to improve girls' education, and women's employment, political participation, and legal status.
Fourth is applied demographic research to estimate the costs and the benefits of reproductive health services, including but not limited to family planning. We need better methods to assess the costs and the benefits of alternative modes of service delivery (village-based vs. clinic-based workers, for example), based not simply on contraceptive acceptance, but on continuing contraceptive practice; not only on family planning performance, but on reproductive health outcomes; not just on fertility impact, but on health impacts. Similarly, extensive operations research is needed to develop and test the most appropriate clusters of reproductive health services, and priorities among them, given both needs and resource constraints. Further, we need to develop and test effective public education messages, beyond the simple family planning messages of the past, and modes of delivery to multiple audiences, including, especially, young people. Finally, we need new evaluation methods and program indicators beyond contraceptive acceptance, "couple years of protection" and the total fertility rate.
Fifth, and critically important, is engaging the population profession in assessing and promoting changes in broader national development policies. The shift from family planning to a wider reproductive health approach has been the central concern so far in the Bangladesh sector work, including some attention to adolescent sexual and reproductive health needs. More challenging even than this work is creation of broader "population policy" for the nation. This requires involvement of ministries of planning, finance, women's affairs, education, labor and rural development and, ultimately, the cabinet, among others. In this regard, the Bangladesh government, a leader in the Cairo negotiations, needs to redesign its overall development strategies and allocation of resources to emphasize gender equity and poverty alleviation. This is a tall order. The population profession, including researchers, technical agencies and donors, could -- indeed must -- assist by redesigning their own conceptual planning tools, by expanding data bases (on, for example, gender differentials in schooling and employment), and by assessing both the costs and the multiple benefits of increased investments in girls and women.
The Cairo agenda, and specifically the research agenda we propose, builds on four decades of family planning research and program experience. The Cairo agenda is a demographic agenda. It offers demographers -- and other population professionals -- unprecedented opportunities to expand our vision, to revitalize and strengthen our field, and to broaden the base of popular and political support for our work. The international population movement can and should do no less to meet the demographic challenges that lie ahead.
Of all the scenes I've witnessed in 25 years of international work, one is particularly haunting:
The place, an emergency ward in Yaounde, the capital city of Cameroun, was a decaying mud brick hulk, floors riddled with potholes and walls covered with mold. One extraordinarily courageous doctor worked there -- with no equipment, no blood transfusion, and, clearly, no beds.
In stunning contrast, not 50 yards away, up the hill out of the swampy area, was a sparkling white, new maternity hospital, fully equipped and staffed -- with plenty of empty beds. The difference between these two places speaks volumes about the stigma and fear that surround abortion -- not only in Cameroun, but around the world.
What is the connection between the women in Cameroun's abortion wards, reproductive health, population, and the environment? For 30 years -- 1965 to 1994 -- U.S. proponents of population control, including environmentalists, pursued a "technical fix" approach to population growth in Asia, Africa and Latin America. They focussed on promotion of modern contraception to the largest possible number of married women of reproductive age. This approach undoubtedly contributed substantially to major increases in the availability of contraceptives and women's use of them around the world. But, the technical fix approach ignored all other aspects of reproductive health.
In 1994, in Cairo, at the United Nations International Conference on Population and Development, women -- and like-minded men -- reshaped the population agenda. The Cairo conference defined population policy to encompass the reproductive health and rights of all, in a broader context of women's empowerment, poverty alleviation, respect for human rights, and sustainable development. Some have attempted to dismiss the Cairo agreement as a feminist utopian vision. In fact, its purpose is the fundamental social transformation that Carol Gilligan so eloquently described this morning. The Cairo approach is also a global necessity. Why?
Most future population growth will be generated by today's young people as they become sexually active -- some one billion of them by the year 2000, an unprecedented number. Even if these young people have only one or two children, population will continue to grow substantially in absolute terms. If the world's population is to level off at 9 or 10 million -- instead of 12 or 15 million -- population policy must change dramatically. These young people need protection from sexually transmitted diseases, not just unwanted pregnancy; they need education on sexuality, sexual relationships and gender equality, not simply the standard biology-based sex education; they need to know that men do not have the right to abuse, beat and rape women; they have a right to good quality health services; and they must have education, job training and real job prospects, so that they can delay marriage and childbearing, and so that a woman's status does not any longer depend largely or solely on the number of sons that she bears.
This "sexual and reproductive health and rights" approach to population could have helped protect the women I saw in Cameroun from rape, unwanted pregnancy and botched abortion. It is a just and expedient approach to population. It was agreed by 184 governments and most demographers. Yet, there is strong political resistance to implementing this agenda -- much of it from the same forces that oppose reproductive rights in this country.
Why are the women in Cameroun -- and the opposition to the Cairo agreement -- relevant to mapping the future of choice in the U.S.? Why should we, as Americans, care?
President Clinton's first major act on entering office was to overturn that policy. Anti-abortionists have pursued him relentlessly ever since. Theirs is a global campaign of intimidation -- even the United Nations and the IMF are not immune, as we saw last fall when Chris Smith held them hostage in an attempt to legislate a global gag rule. Thus, we also must act globally -- we must be as concerned about U.S. foreign policy as we are about domestic legislation.
As I see it, there are two major obstacles on the roads we are mapping in the U.S. and internationally. These are political power and money. What do these two issues look like in the international arena, and what do they mean for all women -- in Yaounde, Shanghai, Sâo Paulo, and Prague; in the villages of Pakistan, Kenya, Egypt and México; and in New York City? First, political power: the international situation is unnervingly similar to that in the U.S.:
The assault on foreign assistance will resume when Congress convenes later this month. Three actions are imperative:
We need to strengthen and broaden alliances between domestically-oriented activists and those who work internationally.
And we must inform our friends, our neighbors, and our communities about the realities of women's lives overseas, and the connection between these realities and their own lives and rights.
All of us here know -- but let us remind everyone in this country -- that restrictive laws are not a matter of culture or religion, but of power. They do not eliminate abortion or save "unborn children." They kill and maim women. They drastically curtail women's autonomy and cast women as criminals. If this happens anywhere, it is a threat everywhere -- including here. I believe, as Faye Wattleton does, that we have the moral high ground -- it is women's lives, our being, our relationship, as Carol said, to our bodies, our voices.
We should not waste energy arguing with fanatics, persuading or cajoling them. Whatever compromises we make, they just take more -- today they restrict access to safe abortion; tomorrow they will restrict contraceptive choices, then day care, or women's rights -- and so the dominoes will fall.
Rather, let us mobilize a broad-based coalition, here, and abroad. As in Cairo, women have the most at stake. Our voices will be heard. We must support women everywhere to organize and advocate on our own behalf, and on behalf of our families and communities. My organization, the International Women's Health Coalition, does just that. Our colleagues around the world watch U.S. law and practice closely. At least four are here today.* They know that, if we lose our struggle here, they will suffer severe consequences. They stand in solidarity with us, and we with them. This solidarity is not one collective voice. It is solidarity of voices across our diversity.
But, these days, to stand still -- even in solidarity -- is to lose ground. We must move strongly forward -- beyond the confines of this room, and beyond the borders of this country -- to rid the world of scenes like the one I witnessed in Cameroun.
Mapping the future of choice is a global task. It requires global mobilization -- now.
| * | Carmen Barroso from Brazil |
| Frescia Carrasco from Perú |
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| Lucía Rayas from México |
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| Reena Marcelo from the Philippines |
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| All leaders in the struggles for women's dignity and autonomy in their countries and around the world. |
In previous seminars in this series, you have heard about current and future rates of population growth, and estimates of how many people the earth can "carry." We have discussed the ethics of decision-making on population control, and examined the multiple values and complex meanings of families. You have heard somewhat different views on what the content and priorities of population policies should be.
Tonight, I would like to talk to you about young people aged 10 to 19. The one billion already born, and the several hundred million more who will join them in the next 15-20 years, are the people who will determine the world's future population size, consumption patterns and environmental impacts. Their choices about sex, marriage and childbearing will determine two thirds of the world's population growth in the next 100 years.
A few of these young people are your children and grandchildren, and those of your friends. But most of the one billion are poor, growing up in poor countries, or in pockets of poverty in the U.S. Their ability to go to school, and to stay in school; their access to health information and services; their opportunities for skills training and employment; and their families' and communities' views about gender roles and power relations, marriage, and childbearing will determine whether world population reaches 10 billion by the year 2100, or 15-18 billion or even more. Who are these young people?
We actually have very little information about them -- especially if they are not married. A recent comprehensive review of research by Barbara Mensch, Judith Bruce and Margaret Greene at The Population Council concludes that most available information about young people in Africa, Asia, Latin America and the Middle East, is limited to standard demographic data on age, years of school completed, age at marriage and first birth, and the like. We know very little statistically about how these young people spend time outside of school, or what their school experiences are like; their work; their self-esteem, or social relationships, or their sexual behavior. We know even less about gender differences in these activities. In fact, we tend to speak only about aggregate "adolescents" not distinguished either by sex or marital status even though differentials by sex and marital status are probably very substantial.
Let me tell you what I have learned about young people through our colleagues in Bangladesh, Nigeria, and Brazil.
In rural villages of Bangladesh, where most people still live, young girls are commonly married off by their parents by the age of 16, or younger. Girls have far less chance to go to school than boys, especially after they have reached puberty. They have few opportunities for remunerative employment, but they work longer hours than boys if you include household work and child care. Girls receive little or no information from their families and schools to prepare them for marriage and sexual relationships. Sexual harassment -- called "Eve teasing" in Bangladesh -- is widespread, and girls who leave their household compounds are not only at substantial risk of rape, but are blamed if something happens to them. If a girl summons the courage to reject a suitor, it is not uncommon for the man to throw acid in her face or find other ways to disfigure her so that no other man will want her. Once married, usually to men who are considerably older, these girls are expected to prove their fertility immediately, preferably by bearing a son. If there is a delay in becoming pregnant, or only daughters are produced, the woman blames herself and is blamed by others. She faces either divorce or the humiliation of a second wife.
A continent away, in Nigeria, the picture is similar in some ways, drastically different in others. Girls are sexually harassed and abused everywhere -- on the streets, in schools, when applying for jobs, and even in their own homes. Under economic pressures, girls and young women fall prey to "sugar daddy" relationships or coerced sex. For example, it has become common for women university students to trade sex for meals or tuition fees that their families can no longer provide. It is also common for school girls to be coerced into sex by taxi drivers in exchange for transportation to school. As in most countries, girls are blamed and punished for the pregnancies that occur. They are forced to leave school or rejected by their parents -- but the men involved are admired for their sexual prowess.
Work by our colleagues in Brazil also shows, however, that boys' sexual initiation and experience can be traumatic. In research and educational programs, boys have reported that their first sexual encounters were coerced and that they felt shame and fear. The coercion comes both from parents who want them to prove their "manhood," and from peer pressure. When sexual initiation is negative and traumatic in this way, is it any wonder that men treat girls and women abusively?
In Cairo in 1994, at the International Conference on Population and Development, the world's governments agreed that population policies should address the needs of young people like those I have described. Until 1994, population policies were directed to married adult women, and focussed narrowly on provision of contraceptive services to the largest possible number. The Cairo agreements recognized that this approach -- not ideal for adult women -- is entirely inadequate for young people, girls and boys, married and unmarried:
The Cairo conference thus mandated a new, broader approach to population policy that encompass two main innovations: first, contraceptive services are to be provided as part of broader sexual and reproductive health services; second, multiple government and non-government agencies, not just ministries of health, are to redesign their programs in ways that support human rights, empower women, foster gender equality, alleviate poverty, and enhance the life choices of young people. The United Nations Population Division currently forecasts that the six billionth person will be born on or about May 14, 1999. We all need to work to ensure that her life -- or his -- is one of dignity, self-esteem, gender equality, and opportunity.
This is a very tall order. It is, in essence, the approach to population policy laid out in the book that the Harvard University Center for Population and Development Studies and the International Women's Health Coalition, prepared prior to the Cairo conference -- Population Policies Reconsidered. Our collaboration with The Center was one of the most rewarding and challenging of my professional life. Implementation of the Cairo agreements requires continuing collaboration of this kind -- among activists, researchers, policy analysts, ethicists, and program managers. As activists, we need the data and analysis that studies centers produce. And they benefit from our practical experience with projects, community leaders, and governments. Together, we can lead the way to policy change.
What, you may ask, can you do? As U.S. citizens, probably your most important contributions at this moment are political:
And, of course, you can also help finance research, advocacy and experimental projects that will provide a basis for lasting social change.
For example, the International Women's Health Coalition provides financial and technical support to five groups across Nigeria who are experimenting with ways to build girls' knowledge and confidence to resist sexual coercion. Based on this experience, our colleagues collaborated on the design of a national sex education curriculum and persuaded the Minister of Education to adopt it. What difference do these projects make? An enormous difference -- one life at a time. Let me end with two examples from programs we support in Calabar, a city in the far Eastern corner of Nigeria. Participants in the Girls' Power Initiative -- GPI -- learn to recognize and exit risky situations. When a potential employer said he would give her a job if she would make a date for a drink with him, a young GPI participant was able to say, "If I am qualified for the job, hire me. But no date!" She turned on her heel and walked out. Another, much younger girl who realized that the motor scooter driver was taking her in the wrong direction, contrived to make him stop and then fled. In a parallel program, boys are learning that their relationships with girls should be built on mutual respect and gender equality.
These examples may seem insignificant, but they are revolutionary in Nigeria -- a revolution whose time has come around the world!
Some came to Colombo burdened with shame and frustration. All of us are galvanized by injustice:
Let us leave Colombo also angry. Anger has a time and place in the struggle against injustice.
The time is now. The place is the highest levels of power we can reach.
Anger is justified: During 10 years of a safe motherhood initiative, six million deaths of women have occurred and millions upon millions of women's lives and health have been ruined. It is not acceptable that, even under the politically comfortable banner, "Safe Motherhood," women's death and illness have attracted so little funding and that political will for change does not exist.
Mahmoud Fathalla, in his opening address, called on women to mobilize. We have mobilized and we continue to nationally and internationally:
But, we've done this primarily with volunteer labor and very little money.
The burden of generating political will cannot be entirely ours -- for reasons of both justice and expediency:
Investments are needed to act on the four "hard lessons" that Mahmoud listed in his opening address, distilled into two:
First: We cannot serve only a few; all pregnant women are at risk.
Second: There is no cheap fix: curative care with all its expense is essential.
Our discussions during this week lead me to add two additional "hard lessons":
Investments in these direct interventions to save women's lives will not, however, be enough:
Let us demand that parliamentarians and other officials who are mostly men:
Let us mobilize ob-gyns, who are still primarily men, to use their considerable power to advocate change, not only provide services.
What commitment shall we demand of our leaders in April?
Imagine if each head of state pledged to allocate to women's reproductive health at least the price of a B-52 bomber, or a MIG, or whatever is the weapon of choice in his country!
That would make journalists take notice -- and we would see front page headlines, not an article buried on the women's page.
The men in this room, including especially Mahmoud Fathalla, who had the first word , and Fred Sai who will have the last word, are stalwart leaders in our struggle. You have dedicated your careers to women's reproductive health. You have witnessed our pain -- and it affected your lives.
Let us, women and men together, mobilize millions more.
As Eleanor Roosevelt said, "There is no more liberating, no more exhilarating experience than to determine one's position, state it bravely, and then act boldly."
We can do no less. The time is now.
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