Risks,
Rights and Reforms
Key Findings
B. Reforms and Risks:
Economic Constraints
C. Rights and Risks:
Socio-Cultural Constraints
D. Women's Health and the
Environment
Introduction
The
United Nations General Assembly convenes on June 30-July 2, 1999 against a
sobering backdrop for the five-year review of implementation of the Programme
of Action adopted by 179 nations at the International Conference on Population
and Development (ICPD) in Cairo in 1994. Uppermost on the agenda is the
shortfall in economic resources that imperils realization of the Cairo
agreement. The ICPD estimated that US$17 billion would be needed by the year
2000 to cover the costs of core family planning and reproductive health
programs identified by the Programme of Action. The share of the international
donor community was US$5.7 billion (adjusted for inflation, this figure is now
about US$6.5 billion), of which only US$2 billion has been delivered so far.
Four countries - the United States, the United Kingdom, Germany and Japan -
account for more than 70 percent of bilateral assistance. Donor countries are
also far from achieving the ICPD goal of devoting four percent of overseas
development assistance to family planning and reproductive health.
While
developing countries have met more than two-thirds of their commitments to fund
reproductive health programs, most of these resources have been generated in a
few large countries. In the world's poorest countries, health and education
spending is a minuscule proportion of gross domestic product compared to debt
repayments. The crushing debt burden of countries in Africa, Latin America and
parts of South Asia makes their family planning and reproductive health
programs heavily dependent on donor aid in the short term, the outlook for
which is less than promising.
Overshadowing
the issue of lack of funds is the global economic crisis, precipitated by the
unregulated flow of transnational capital that began in Thailand in July 1997,
rocked south-east Asia and Russia and by January 1999 was shaking Brazil and
Latin America. The Asian financial crisis has led to drastic cuts in social
sector spending in countries in the region that have long invested strongly in
health and education. Coupled with precipitous devaluation of national
currencies, this has placed food, medicines and other essentials beyond the
reach of large sections of populations. Malnutrition among women and children
is sharply on the rise. Massive job losses and rise in poverty across the
region, especially in Indonesia, and the lack of social safety nets and
unemployment benefits have thrown millions of families into acute distress. In
Russia, the number of people living below the poverty line is now an estimated
30 per cent, up from 18 per cent in 1996. In Japan, the economic crisis has
spawned a growing category of new poor who are not covered by any form of
health insurance.
The
unprecedented economic crisis in Asia has forced important proponents of the
free-market ideology, including the World Bank, to acknowledge that
globalization and liberalization prescriptions can wreak havoc in the absence
of strong legal and banking systems and controls on international financial
flows. But this is small consolation given what accelerating globalization has
already wrought: staggering increases in income disparities, widening
North-South development gaps, massive social exclusion of populations and a
rise in crime, violence and sexual trafficking. Women make up 70 per cent of
the world's 1.3 billion absolute poor. In every country and community, they are
first in the line of fire, bearing the brunt of human and social costs of
crisis and transition. Women's heightened risks as a result of current economic
policies are in poignant contrast to the universal recognition of women's
empowerment as a key to development that has been enshrined in all the UN
conferences of the nineties.
The
social, political and institutional instability created in beleaguered
economies struggling for survival is not conducive to advancing goals of human
development and addressing environmental concerns. Unregulated movement of
toxic materials and increased use of pesticides in agriculture to meet the
demands of a global economy have resulted in devastating health effects,
reproductive health in particular.
In the
five years since governments adopted the Programme of Action, the enabling
environment of sustainable development, respect for human rights and equality
essential to fulfil its promises has thus come under severe attack from a range
of forces. Globalization, privatization and fiscal austerity policies have cut
public spending and services without denting the debt burden of poor countries.
Economic reform policies in general have led states in rich and poor countries
alike to withdraw from their role as primary provider of social services.
Through
the nineties, governments have started to implement reforms designed by the
World Bank and other donors aimed at improving the cost-effectiveness of public
health systems. Health sector reforms have introduced market principles of
efficiency and viability in the vital social sector and, in effect, led to a
competing reality with that of human rights and social justice envisioned at
Cairo. Market reforms imposed on top of economic crisis have dealt public
health services a body blow in countries experiencing acute pangs of economic
transition, such as Russia and the Ukraine.
The
reports in this survey add to accumulating global evidence of the erosion of
equity and rights-based approaches in health as a result of the economic
environment. At the same time, they attest to the efforts of individual
countries to advance the goals of the Programme of Action under difficult
political and social conditions. The 1994 ICPD and the 1995 Beijing women's
conference have fostered the growth of new and creative partnerships between policy-makers
and civil society, including non-governmental organizations, legislators,
community and religious leaders and the private sector. These strategic
alliances have enabled a significant number of countries to act on their Cairo
commitments, reinforced by those made in Beijing.
A.
Moving Forward
The
Programme of Action represented a seismic shift in the thinking on health and
population policies. It challenged traditional family planning approaches that
focused on averting births rather than human well being. It affirmed women's
unencumbered right to reproductive choice and freedom. The ICPD Programme not
only made reproductive rights the centerpiece of family planning programs. It
articulated a holistic concept of reproductive health in the context of primary
health care that encompasses family planning counseling and services, pre-natal
and post-natal care and safe delivery, prevention and treatment of infertility,
treatment of reproductive tract infections and sexually transmitted diseases,
prevention of abortion and management of the consequences of abortion. Gender
equality and equity are at the heart of the Cairo agenda. They are addressed in
the preamble and principles that provide the framework for the Programme of
Action, and also form the subject of an entire chapter.
In the
five years since ICPD, governments, NGOs and UN and other donor and
international agencies have worked in a number of ways to advance the goals of
reproductive and sexual health and rights articulated in Cairo. The Programme
of Action, reaffirmed by the Beijing Platform, has in many instances provided
momentum and direction to pre-Cairo government policies and women's health
advocacy. New initiatives range from adolescent sexual health education
programs to the creation of ministries for women's affairs, integration of
HIV/AIDS prevention in reproductive health services, redesigned programs for
reproductive health and family planning, stiffer penalties for sexual offenses,
improved maternity laws, and research and programs addressing environmental
links to health.
Twenty-eight
countries report that reproductive health is an explicit part of national
health policy. In Mali, the 1998 national action plan for women contains the
first official reference to reproductive health. In the U.S. and New Zealand,
which do not have a national health policy, reproductive health is part of
programs and services. Reproductive health terminology is not part of Italy's
national health plan, but the country's network of family health counseling
centers provides a wide range of required services.
Some of
the most visible advances have been in the scope of reproductive health
services. The Programme of Action has influenced redesign and delivery of
services in countries such as China, Colombia and Korea. The U.K. and Nigeria
have established reproductive health programs with male involvement. Public
health systems provide screening services for female cancers in a number of
countries, including Australia, Brazil, Chile, Costa Rica, Mexico, New Zealand
and the U.S. HIV/AIDS prevention and treatment are part of reproductive health
services in Germany, Korea and Senegal; Germany also has a pilot project
specifically for women with AIDS. Adolescent sex and health education programs
are a priority in Cuba, Germany and Jamaica. Free primary health care for women
and children under six years is a cornerstone of South Africa's reproductive
health policy and marks an important shift from curative to preventive care.
Despite
the crippling effects of the U.S. economic embargo, Cuba's public spending on
health has increased steadily. India made a major policy shift in 1996 when it
released family planning from centrally mandated targets. Indonesia's family
planning program has also tried to overcome its strongly target-driven
practices and adopt client-centered methods - a shift now jeopardized by the
economic crisis. Iran's reproductive health spending has more than doubled to
six per cent of the total health budget since 1994. Zimbabwe has introduced
reproductive health in population and health policy guidelines.
Norway
has allocated half of its reproductive health assistance to Africa.
The
Netherlands has maintained a high level of international population assistance
relative to its economy and has more than doubled funding for population and
reproductive health between 1994 and 1996. U.S. population assistance is moving
from its traditionally strong family planning focus to a more integrated
reproductive health approach. U.K. donor aid provides funds for projects in
critical areas such as post-abortion care and sexual violence.
The
U.K. and Canada have programs addressing the links between breast cancer and
the environment, especially pollution. New federally funded initiatives in the
U.S. include a Long Island Breast Cancer Study and studies funded by the
Department of Defense Breast Cancer Research Program to analyze women's
environmental exposures.
The
successes documented in this survey are especially a tribute to the efforts of
women's health advocates in advancing the feminist vision of the Programme of
Action. In the majority of countries, it is women activists who have been
catalysts of change. Through tireless campaigns and coalition-building, they
have wrested victories in some of the most contested areas in the Programme of
Action, such as reproductive and sexual rights, adolescent sexual health and
education, and harmful traditional practices. In many countries, it is women's
energy, resilience and resourcefulness in face of daunting political and
socio-cultural obstacles that have kept the Programme of Action alive. In the
process, women's NGOs have often taken on responsibilities that governments
have been unwilling or unable to handle. Specific NGO partnerships with
governments have been in service delivery, policy-making and health and sex
education.
Building
Coalitions
A key
strategy adopted by women's NGOs to advance Cairo goals has been to build broad
alliances with a range of civil society actors to overcome conservative
challenges to reproductive choice and freedom. Egypt's FGM Task Force, composed
of activists, researchers, doctors and feminists, played a pivotal role in
broadening debate on the sensitive and charged issue of female genital
mutilation and creating a climate for a political ban on the practice.
Government-NGO coalitions are emerging in Mali and Nigeria to fight FGM and
violence against women.
The
Argentinean experience shows how alliances between health professionals,
community members and church can work in a repressively conservative
environment. Reproductive health services were introduced in 1998 without
opposition of any kind in the province of Buenos Aires, which has a third of
the country's population. A law endorsing creation of a family planning program
for women was also the result of such alliances. In Korea's male-dominant
culture, women's groups have been vocal and active in promoting sex education
stressing gender equality and raising funds to fight domestic and other forms of
violence against women.
In
Australia, women activists launched a massive community campaign with support
from a woman member of Parliament to remove abortion from the criminal code in
1998. In Bangladesh, women health providers, NGOs and community leaders have
mobilized to take up women's health concerns and have worked with the
government to develop the new health and population program. In Brazil, the
National Council on Women's Rights was revitalized with greater political clout
in 1995. The Council worked with the National Commission on Population and
Development to defeat an anti-abortion provision in Congress in 1996. Similar
alliances between activists and policymakers in South Africa led to the
historic Choice of Termination of Pregnancy Act in 1997, the first of its kind
in Africa. In Sri Lanka, an emerging partnership between NGOs and women
legislators calls for legalization of abortion services.
Drawing
on the Beijing Platform commitments, NGOs have also collaborated with
governments to establish institutional mechanisms for women's rights. There are
new ministries for women in Colombia, Costa Rica and Mali. China, Fiji, Iran,
Mali, and Nigeria have launched women's action plans stemming from both the
Cairo and Beijing conferences. Government and NGOs in Zimbabwe have begun
national consultations on a new gender policy.
In some
instances, women have slowly expanded the space offered them by the state to
become creative and vocal agents of change. In Iran, an association of
volunteer women health workers set up by the government to attend to women's
family planning and general health needs in congested and under-served urban
areas, has acquired a life and will all its own. Now more than 20,000 strong,
these community health workers have become empowered in the family and
community and enlarged their sphere of activities, organizing around community
and environment issues and, in some cases, publishing their own newsletter. To
the chagrin of the government, which saw them as effective but docile agents of
family planning, the volunteer women are now an organized force seeking a
greater role and political voice.
In many
countries with discouraging political and social environments, NGOs have worked
with governments to make decentralized policymaking a reality. In Bangladesh, a
pilot project to promote participatory planning with communities forged ahead
thanks to the persistence of activists, overcoming the resistance of government
officials. In strife-torn Algeria, a cooperative committee of citizens and
youth is collaborating with government and NGOs to address the spread of HIV
and sexually transmitted diseases and devise policy responses to the slaughter
of civilians by armed insurgents. A newspaper campaign in Uganda targets
adolescents on sexuality and reproduction issues. Botswana's youth clinics have
taken on reproductive and sexual health education and service delivery to stem
the rampant spread of HIV.
In
Canada, women's advocacy efforts have impelled successive governments in
Ontario to help community health centers provide counseling and services for
refugee women and undocumented migrants. In the U.S., where HIV/AIDS is a top
killer in the African-American community, the Congressional Black Caucus made
the issue a top priority of its 1998 agenda. Working with health care
professionals, activists and community leaders, it has got the federal
government to designate this as a public health emergency and develop a package
of initiatives to address it.
Women's
advocates have spearheaded legislation against discrimination and violence in
many countries. Korea's new law banning the pernicious practice of sex
selection of fetuses to abort girls is one example. In Botswana and Tanzania,
women's activists have worked with government bodies to bring about stiffer
penalties for rape, especially for rapists who are found to be HIV-positive.
These
achievements are all the more remarkable in light of the fact that the concept
of comprehensive reproductive health that takes a life-cycle approach to
women's health as defined in the ICPD Programme is still struggling to emerge
in a number of countries. In Senegal and Morocco, women activists report that
their governments have adopted ICPD principles in spirit but not absorbed them
in practice. In South Africa, despite progressive and far-sighted changes in
health policy and the presence of a strong and sophisticated women's health
movement, reproductive health is used interchangeably with women's health in
the White Paper that sets out policy.
In
others, the policy shift to reproductive health is merely semantic; the
approach remains rooted in family planning and fertility control. These
old-style practices have proven especially hard to dislodge in countries with
long-standing family planning programs aimed at population control. They are
still the norm in the three populous countries of South Asia - India, Pakistan
and Bangladesh - and China, despite encouraging new initiatives there aimed at
doing away with demographic targets and expanding women's health services at
the village level. By and large, new orientations after ICPD have not
significantly deflected from the official view of women primarily as mothers,
with little regard for their health needs before and after their reproductive
years.
The
focus on female methods of contraception and sterilization also remains
unchanged in these countries and Iran and the Philippines, to name a few.
Despite new efforts by the Chinese government to involve men in family
planning, only nine per cent of men undergo sterilization compared to 40
percent of women. Nicaragua's National Health Plan makes no mention of male
responsibility in family planning and has no provision for reproductive health
programs for men. In Peru, activists uncovered gross violations of women's rights
in sterilization procedures under the state's family planning program in 1996.
Bangladesh activists report that incentive payments to providers of
sterilization were resumed after ICPD.
Given
the lack of conceptual clarity and the persistence of demographically-driven
approaches, it is not surprising that an overwhelming number of respondents say
that reproductive health services offered do not meet women's needs. The
greatest shortcomings are reported in pre- and post-natal care - an area in
which vast rural-urban disparities persist - availability of contraceptives,
emergency obstetric care, post-abortion care, services for post-menopausal
women, detection and screening services for female cancers and male
responsibility for family planning.
Donor
funds play a key role in defining the scope and direction of reproductive
health in national health policies and programs. With declining levels of aid -
since 1996, all major bilateral donors have had their budgets cut, USAID by as
much as 35 percent - donor agencies are under greater pressure from their
governments to show measurable achievements for funds allocated. This fosters a
reliance on numerical indicators of "success" such as contraceptive
prevalence rates and fertility rates. The result is that client governments are
under increasing pressure from donors to emphasize family planning above all
other components of reproductive health, or promote long-acting methods,
regardless of health concerns voiced by women activists. NGOs in Egypt and
Bangladesh, for example, point to both these disturbing trends, which raise
critical issues of the nature of partnerships among government, bilateral and
multilateral donors and civil society.
B. Reforms and Risks: Economic Constraints
Declining
trends in donor assistance, structural adjustment policies that curb social
sector spending, health sector reforms that aim to make public health systems
cost-effective, the serious debt burden of many countries in the South and
recent economic crises all pose challenges to the achievement of Cairo goals.
The world's poorest countries owe an estimated US$371 billion in external debt,
and are also faced with acute levels of human and environmental distress.
Nigeria's external debt exceeds a full year's GNP. Tanzania spends nine times
as much on debt repayments as on basic health care and four times as much on
debt as primary education. In Peru, debt servicing consumes 22 percent of total
government spending, compared to seven percent on health. Policy reforms that
curtail public expenditure have deepened poverty and inequity in developing
countries. All respondents to this survey cite economic reforms as paramount
constraints in implementing the ICPD Programme. Health sector reform in particular
is emerging in most countries as a challenge to expansion to reproductive
health services.
Health
Sector Reform
Health
sector reform has become an integral aspect of adjustment policies stressing
market principles in the social sector. It has been introduced in a host of
developing countries, with similar processes underway in industrialized
countries with established social welfare systems. The overall goal is to
minimize the bureaucracy and inefficiency of overly centralized systems and
make health spending cost-effective by re-organizing services and resources.
Some of
the means employed are decentralization of management and budget to make the
health sector more accountable to users by ensuring district and community
participation; introducing cost-recovery mechanisms such as user fees and
insurance; encouraging greater private and other non-governmental sector
participation in health delivery; and modernizing administration through
financial and management information systems. In the 'reformed' health sector,
the state stays responsible for no more than a basic health package, whose
components can vary depending on a country's level of development.
There
are clear benefits, in principle, in several health sector reform measures,
such as shifting decision-making and responsibility from central to local
authorities and the community, and integrating vertical management structures
for greater efficiency. But problems arise from the technocratic and sectoral
approach of reform to health as a discrete commodity, unrelated to
environmental, social and economic factors. Further, health sector reform is
based on some untested assumptions: that swathes of poor populations have the
ability to pay for health care, and that governments in developing countries have
the capacity to back reform measures with managerial, technical and financial
resources. While holding the promise of greater accountability and
responsiveness of health systems, in reality, health sector reform has in many
instances eroded equity of access to health services.
Decentralization
has most often taken the form of governments shedding responsibilities to the
provinces or districts without allocating resources. Cash-strapped local
authorities cannot make local services viable because of the poor purchasing
power of most of their users. The imposition of user fees has placed basic
services beyond the reach of the poor, women in particular, with disastrous
health effects. Prescription medicines, basic medical supplies and
consultations that were previously free must now be paid for, forcing many of
the poor to delay health care and risk disease and death. The income exemption
limit for user fees suggested by the World Bank has often failed to take into
account inflation and currency devaluation and is too low in many countries to
protect vulnerable populations. Contrary to Bank guidelines that fees collected
stay in the local health facility to improve services, governments often use
this revenue to stabilize national budgets to meet stringent targets for fiscal
stabilization. As a result, health services have not only deteriorated in
quality but become more expensive.
Lay-offs
of public health personnel and wage freezes in the public sector have also
contributed to a decline in quality of services by collapsing morale, prompting
an exodus of health professionals to the private sector or abroad.
Employment-linked health insurance in the formal sector means that the primary
bread-earner, usually male, has access to employer-sponsored health services,
while women and children in the family have to use fee-for-service facilities.
Public sector lay-offs as part of overall structural adjustment not only strike
at this slender provision of health, but also increase the work and disease
burden of women. They have to take on the role of primary caregiver in the
family as well as put their own health needs last. Like all other adjustment
policies in the social sector, health sector reforms have defined efficiency
without taking into account the enormous human cost of coping strategies
adopted by the poor, women in particular.
Charging
Fees
The
majority of countries in this survey report some or all of these effects of
health sector reforms. Cost recovery tops the list, cited by 70 per cent of
countries as resulting in several adverse health consequences for women.
Zimbabwe provides an object lesson of the ways in which World Bank and
government calculations of the role of user fees have gone tragically awry. An
OXFAM study cited in this report found that fee structures introduced in 1994
raised primary care costs six-fold. Antenatal care previously free cost Z$10.
Strict enforcement of fee collections led to a fall in out-patient attendance
by 18 percent and a 12 percent rise among in-patients, suggesting that people
were delaying health care until absolutely necessary. Antenatal clinic
attendance fell, while admissions of unregistered mothers and babies born
before arrival rose more than 20 percent. The maternal mortality rate among
these women was five times higher than for women who had pre-natal care.
In
Nigeria, women must now pay for blood and blood products and use of equipment
and even bring their own candles to hospitals in case of a power outage during
delivery. In Uganda and parts of Tanzania, poor women can no longer afford the
cost of pre- and post-natal care and have to resort to traditional midwives. In
Sri Lanka, patients are increasingly required to pay for basic services in
public health systems, such as medicines and injections.
Privatization
Fifty-four
percent of countries report that privatization trends have weighted the odds
against access to health services by the poor, women in particular, the elderly
and immigrant and minority populations. Privatization of public services and
competitive market mechanisms increasingly characterize the health systems of
rich and poor nations alike known for extensive and long-standing
state-supported social programs, such as The Netherlands, New Zealand, Russia,
India, Indonesia, Tanzania and Zimbabwe. In the Philippines, privatization has
led to the sale of government land and closure or scaling down of vital public
hospital services in mental health, leprosy and TB. In Sri Lanka, Tanzania and
Egypt, medical staff in public facilities invest more time in private practice
to the detriment of quality of public health services. Tanzania and Kenya have
the dubious reputation of being the biggest "exporters" of qualified
medical personnel from the region to southern Africa.
In New
Zealand, health sector analysts note that public hospitals have been
transformed into commercial enterprises, required to operate not as caring
institutions but successful businesses. Government officials say that health
rationing is now a fact of life. In 1997, there were 86,000 people on public
hospital waiting lists, 20,000 more than when reforms began. In the U.S., when
privatization has led to health institutions being taken over by Catholic
administrations, women face a double burden: reduced access and denial of
reproductive health services on religious grounds.
Simultaneously,
the removal of price controls on pharmaceuticals and the opening of domestic
markets to multinational corporations under globalization have added to health
care burdens. Medicine costs have soared 300 percent in Egypt. NGOs in Algeria,
China, India, Morocco, the Philippines and Russia report that spiraling costs
of medicines are a growing barrier to health care. In China, treatment for
common ailments is prohibitively expensive: a typical prescription for Western
drugs can cost US$60, or half a month's salary for an urban worker. In India,
the increased cost of medical care is the second most common cause of rural
indebtedness. Women place their health needs last when cost is an issue,
seeking medical care too late or not at all.
Decentralization
Fifty-two
percent of countries, Bulgaria, Canada, India, Mali, Pakistan, the Philippines,
Russia, Senegal and South Africa among them, point to decentralization of
responsibilities without adequate resources, a phenomenon endemic among
countries in Latin America. Canadian activists say that the shift in
responsibilities from provincial to regional authorities has occurred without
allocation of new resources, creating a funding crisis in community health
centers.
India's
formal rural health infrastructure is beset with problems and offers limited
services of poor quality. In the Philippines, many local governments are too
poor to assume health care responsibilities, and pass patients back to
nationally funded tertiary centers or NGOs. In Pakistan, decentralization to
improve service delivery under the Social Action Program has fallen short of
goals, especially in rural areas. Only a third of communities surveyed in an
independent study had health facilities, with less than half of male doctors
reporting for work.
Cuts
in Budgets and Public Services
Forty-four
per cent of countries report cuts in public health services. In Costa Rica,
reforms have reduced per-capita health spending, and led to stagnation of
public services and cutbacks in health services covered by the social security
system. Poor women have less access to services of specialists such as
gynecologists; in Argentina, they have to wait from dawn to midday to see a
doctor. Long waiting periods and inconvenient clinic hours are further
deterrents to women seeking health care.
Budget
squeezes that lead to closure or emasculation of public hospitals particularly
affect women because these are the only institutions that provide reliable care
with equipment and staff for quality obstetric-gynecological services. This is
the experience of Peru, where reforms have increased the number of health
centers but more than halved the number of public hospitals in the last six
years. In Russia, the transition from state-supported health services to a
market economy has thrown the health system out of gear. Budget cuts have
forced closure of hospitals in rural areas and cutbacks in emergency obstetric
services.
The
Bulgarian and Ukrainian experiences with abortion shows how market forces have
placed women between a rock and a hard place. Abortion is legal and
traditionally the main method of birth control. Women resort to abortion in
large numbers even though it must now be paid for and despite the fact that
abortion is a major cause of secondary infertility. Activists say this is
because government budgets provide no funds for public education on the damage
caused by repeated abortions and most women cannot afford contraceptives at
market rates - 15-40 percent of average monthly income in Bulgaria.
Prevention
of unwanted pregnancies must always be given the highest priority and every
attempt should be made to eliminate the need for abortion
Programme
of Action, 8.25
More
than a fourth of respondents, Australia, Argentina, Canada, Morocco, Russia,
Tanzania, Turkey, the Philippines and Sri Lanka among them, report cuts in the
health budget as a result of economic reforms including structural adjustment.
Inflation, currency devaluation and monetary crises have offset the impact of
budget increases in most other countries. Moreover, public investment as a
proportion of total health spending is declining in many developing countries,
where the poor are seen as consumers of private health care. In India,
household spending on private health care accounts for five percent of total
consumption expenditures in rural areas, and two percent in urban areas.
HIV/AIDS
Burden
Health
sector reforms have been put in place at a time when the imperatives for public
investment in health are the greatest - whether because of increasing poverty
and social exclusion as a result of structural adjustment and economic crisis,
as in parts of eastern Europe and Asia, or the HIV/AIDS pandemic ravaging
entire countries and generations in parts of Africa. The stupendous demands on
systems and resources created by galloping rates of HIV infection have brought
health systems in worst hit countries to the verge of collapse and reversed
significant gains in reducing maternal and infant mortality. Forty-two percent of
countries report the increased costs of HIV/AIDS treatment as a burden on
over-stretched health systems.
In
Botswana, where one in four people are infected with HIV, pregnant women who
are HIV-positive can receive AZT free of charge only in the first trimester.
Women are especially vulnerable to infection because of physiological factors
that predispose them to infection, their lack of bargaining powers in
negotiating safe sex and their economic dependence on men. HIV infection rates
are rising among women in Argentina, India, Japan, Kenya, the Philippines,
South Africa and Zimbabwe. HIV/AIDS is also spreading rapidly among the young,
with 2.5 million people aged 15-24 and 600,000 children under 15 catching the
virus in 1998. The UN estimates that six young people are infected with the
AIDS virus every minute.
C. Rights and Risks: Socio-Cultural Constraints
The
women's health and human rights movement has acquired unprecedented visibility
and pre-eminence through the Cairo and Beijing platforms. In asserting their
rights, however, women have had to contend with an array of opposing forces,
old and new, that have grown in strength and number. NGOs in every region of
the world report that conservative forces in various guises, predominantly
religious, represent key obstacles to the advancement of Cairo goals. Religious
and cultural resistance to reproductive rights is the greatest - although by no
means restricted to - countries that entered reservations to the Programme of
Action's commitments on abortion, adolescent sex education and services, and
sexual and reproductive rights. The power wielded by these forces is most
evident in restrictions on abortion rights and adolescent sex education and
services - two highly contested aspects of the Programme of Action.
Conservative
Forces
Religious
forces, especially the Roman Catholic Church and its Rome-based affiliate, Opus
Dei, oppose reproductive rights in various ways. Common tactics are public
campaigns against abortion and contraception in schools and the media,
especially targeting health providers and thereby affecting the delivery of
reproductive health services, and influencing policy-making. Some of the
hardest battles for reproductive rights are being waged by women in Latin
America, where key government officials are openly and staunchly allied to the
Catholic hierarchy. Activists report that anti-choice groups in this region are
also buoyed by substantial support from ultra-right wing forces in the U.S.
In
Nicaragua, women's groups say that a new Ministry of Family is the single
biggest constraint to advances on reproductive rights. Its minister, an Opus
Dei affiliate, has vowed to outlaw anything that "disintegrates the
family," such as extra-marital sex and divorce, and to campaign for
natural methods of contraception such as rhythm and withdrawal. In Argentina,
reproductive health is not part of national health policy and women activists'
efforts to introduce it in legislation, with support from women policy-makers,
has been stymied by the Catholic Church in all but two provinces. Costa Rica
has kept reproductive health out of official national policy to avoid
interference from the Church, while Guatemala has chosen not to have one out of
deference to the Church and other conservative quarters. In Mexico, right-wing
groups such as Pro-Vida, Human Life International, the Opus Dei and Christ's
Legionnaires, oppose all forms of contraceptives, abortion even in cases
permitted by law and adolescent sex education.
Activists
in the Philippines also report the pervasive and repressive influence of the
Catholic Church. To counter ICPD goals, Catholic alliances have sought key
positions in local government, pushed for legislation against family planning
and abortion, campaigned to replace population education with "pro-life
sexuality modules" and proclaimed that tetanus vaccines are
abortifacients.
In
Poland, the anti-abortion law of 1993 made abortion illegal, overnight
abolishing the provision for abortion on social grounds that had been legal
since 1956. The provision was restored briefly in 1996, and withdrawn again by
the conservative government in 1997. Alongside, the Catholic Church has kept up
a relentless campaign against modern contraceptives, characterizing their use
as ineffectual, harmful and sinful. The influence of Catholic and other
conservative forces has stopped approval of Mifepristone in Australia and
ensures that abortion is a crime in most states. In the U.S., women activists
point to the "pervasive moral zealotry" of conservative forces that
has led to unrelenting violent attacks on reproductive rights, especially
abortion, and opposition to family planning programs at home and abroad.
In
parts of West Africa, women report that Islamic conservatism is flexing its
muscle to counter women's voices for sexual rights and reproductive choice.
Muslim women's associations have sprung up in Mali with funding from Arab
countries to discourage contraception and protect FGM. Militant Islamists in
Algeria have committed horrific acts of violence against women deemed
"enemies of Islam." Activists report that while the state opposes the
Islamists militarily, it accommodates fundamentalist pressure on key women's
concerns, such as marriage and polygamy.
In
Argentina, on the other hand, with women legislators as allies, activists have
defeated attempts by the state to introduce constitutional provisions seeking
to protect life from the moment of conception. In Brazil, women's health
advocates have staunchly countered many conservative attacks on abortion rights
and launched signature campaigns to convince lawmakers to support a 1997
abortion law.
Restrictions
on Adolescent Sex Education
Adolescent
sex education is under attack from the Catholic hierarchy and other conservative
forces in Australia, Chile, Costa Rica and Mexico, to name a few. These are
also among the countries where sexual activity begins early and teen pregnancy
rates are unusually high. Young people aged 15-19 in Mexico have the lowest
rate of contraceptive use. Childbirths among women in this age group account
for more than 15 per cent of total births. Costa Rica reports a 20 per cent
rise in teen pregnancies over 1996-97. Thirty per cent of young people polled
in a survey said they get little information about pregnancy.
Failure
of the health system, even in industrialized countries, to meet critical sexual
and reproductive health needs of young people is reflected in high rates of
abortion and sexually transmitted diseases in this population. With almost one
million pregnancies among adolescents each year, the U.S. has among the highest
teen pregnancy rates in the industrialized world. So does the U.K., with 30 per
1,000 live births in 1997. Pregnancy and abortion rates are sharply on the rise
among young women in Japan, where sex education at schools, homes and in the
media is almost non-existent. The government remains oblivious, with the
Ministry of Education taking the stance that it "is best not to wake a
sleeping child." Abortions among young women account for 33 per cent of
the total in Korea, where activists report that education on family planning,
sexuality and gender relations is inadequate and outdated.
Restrictions
on Abortion Services
Abortion
remains illegal and/or restricted to varying degrees by law in most countries
of the world. Although Paragraph 8.25 of the Programme of Action does not call
for universal legal and safe abortion, it does call for greater actions to deal
with the health impact of unsafe abortion. Most importantly, in emphasizes that
"in all cases, women should have access to quality services for the
management of complications arising from abortion." The vast majority of
countries in this survey are far from fulfilling this requirement. Lack of
resources to provide post-abortion care is only part of the reason. The larger
influence is from conservative forces that reserve their most virulent tactics
for abortion. Even in countries where abortion is permitted by law to save a
woman's life, women can be denied the procedure by doctors and other health
providers on religious grounds. They also have to endure humiliating and
time-consuming formalities at the hands of the police, courts and other
bureaucratic bodies, with often fatal consequences. Activists in Argentina,
Nicaragua and Peru report these trends.
In the
U.S., since 1993, there have been seven murders of doctors and workers in
abortion clinics and 14 attempted murders. In 1997 alone, nearly a fourth of
abortion clinics nationwide were targets of violence and threats. In Canada,
where abortion is legal and available without restriction on reason, the
right-wing swing in many provinces and the election of anti-choice advocates in
local governments, coupled with deficit-cutting cutting measures as part of
decentralization, have led to cutbacks in family planning and abortion
services. In Norway, the Christian Democrats in the governing coalition are
seeking to restrict the 1978 law on abortion on demand, creating new fears of a
rightward shift.
Seventy-seven
per cent of anti-abortion leaders are men. 100 per cent of them will never be
pregnant - Advertisement of the Pro-Choice Public Education Program in New York
City subways
Several
countries cite the criminalization of abortion as the biggest contributing
factor to the persistent tragedy of maternal mortality, an area in which
governments have made the least progress since ICPD. Illegal abortion is cited
among the highest causes of maternal death by a number of countries surveyed,
including Argentina, Chile, Colombia and Guatemala. By contrast, Italy's
experience with abortion confounds conservative critics. Legalization and safe
and affordable access, along with expanded family planning choices, has reduced
the number of abortions, especially by preventing clandestine operations.
Negative
Male Attitudes and Discrimination
Male
attitudes of control and subjugation, especially in sexist and patriarchal
cultures, are another category of persistent socio-cultural constraints. These
are often institutionalized in law or practice. In India, for example, contrary
to government guidelines, health providers often seek male authorization for
women seeking abortion. In Iran, women must get spousal authorization for all
forms of contraception, especially tubal ligation. Korea's dominant male
culture causes women to care for the health of men while ignoring their own,
even when they are sick. In Botswana, although 90 percent of the population is
aware of how HIV is transmitted, extra-marital affairs are the norm among many
men, who also refuse to use condoms with their wives. In Algeria and Senegal,
women say that opposition from husbands is a main reason for failure to use
contraception and spread of sexually transmitted diseases. Tanzanian men oppose
contraception because they believe it causes women to be promiscuous.
The
attitudes of health providers, often influenced by class, community, race and
gender, deter women from seeking professional care. Activists in Mexico report
that authoritarian attitudes of health providers and their belittling of
symptoms undermine the principles of equity in reproductive health services. In
India, the attitude and the quality of care provided by staff in public clinics
changes with a woman's socio-economic status. Poor and unmarried women often
have to seek care in the private sector as a result. Discrimination, denial and
destitution still characterize the world of women HIV/AIDS patients in many
countries, even in countries with exponential increases in infection and
disease.
Such
discriminatory attitudes become pronounced deterrents to health care for women
of ethnic and racial minorities. When accompanied by a lack of government
attention to the health status and needs of these groups, this leads to a
failure to recognize the differential health status of minorities. Activists in
Canada and Costa Rica, for example, point to the failure of the health system
to address the high rates of breast and cervical cancer among women of African
descent in these countries. In the U.S., ectopic pregnancy, a consequence of
untreated STDs, is the leading cause of death in early pregnancy among
African-American women.
D.
Women's Health and the Environment
The
Programme of Action highlights the links between increasing population,
environmental changes and sustainable development. Principle 2 recognizes the
fundamental right of all people for a life "in harmony with nature."
Principle 3 emphasizes the need for a dynamic balance between population,
resources, the environment and development to ensure the well being of all
people. Key to these goals is the basic human right to adequate food, housing,
water and sanitation. Agenda 21 adopted at the 1992 UN Conference on
Environment and Development emphasizes the goals of sustainable development
that relate to gender equity. Assessment of progress on connections between
gender, environment and development include examination of a gender focused
approaches towards education, training, data gathering and assessment and
enhancing women's role in decision-making with respect to the environment.
Environmental
threats stem from traditional problems related to poverty and development
including lack of access to safe water, poor sanitation, food contamination,
indoor air pollution from cooking, inadequate solid waste disposal,
occupational hazards in agriculture and cottage industries, natural disasters
and disease vectors. In many countries, the World Health Organization has found
that a "risk transition" is occurring, placing people in double jeopardy,
as traditional environmental health hazards are exacerbated by new threats.
While surface-water sources were already contaminated by sewage, groundwater
sources are now polluted by industrial wastes seeping into water tables. Air
pollution from vehicular transportation, power plants and industrial sources is
on the rise, especially in rapidly growing urban areas. Exports of wastes and
obsolete technologies from 'developed' countries brings with it modern dangers
of chemical and radiation hazards. Rapid urbanization has combined with rapid
industrialization to double total industrial waste in parts of the world. The
drive for economic growth is pushing countries to over-exploit natural
resources including timber, fossil fuels and minerals, resulting in
unprecedented deforestation and land degradation.
While
environmental threats affect hundreds of millions of people, causing increased
illness and disability, women are often those who are most sensitive to changes
in the environment because they are in closest contact with the home and the
land and they are the first line of defense when threats face the family system
as a whole. Survival of women and their families is closely linked to the
health of the land, forests, fisheries and other natural resources on which
their survival depends. Women's health is essential to ensuring the safety of
future generations. It is women who must guide the growing child through the
most fragile stages of development. There is strong evidence in this report of
the irrevocable damage caused by environmental assaults during various stages
of the life cycle, but particularly to the fetus and growing child.
The
report is also a testimony to the struggles women wage in the face of growing
environmental degradation. In developing countries, one in five children will
not live to see their fifth birthday, most because of avoidable environmental
threats to health. This translates into roughly 11 million avoidable childhood
deaths per year. As caretakers and mothers, women bear the brunt of this pain
on a daily basis.
Women
throughout the world have been innovative in their response to these problems.
In the U.K., where breast cancer mortality is the highest in the world, women
are working to map environmental exposures that may be linked to the disease.
In the U.S., women have emerged as some of the most active leaders in
community-based grassroots environmental organizations. In China, women all
over the country are being trained in environmental protection and sustainable
development, and are in turn training other women. In Kenya, women activists
plant trees. In Nigeria, they have come together in the Ogoni region to fight
the impact of oil pollution in the Niger Delta.
Water
Pollution and Supply
At
every UN conference from Rio to Rome, governments agreed to ensure universal
access to safe drinking water in sufficient quantities by the year 2000. Yet
one billion people lack access to safe water supply. The UN estimates that 40
percent of the world's population, living in 80 countries, suffer from severe
water shortages. No region of the world is likely to reach full coverage with
safe drinking water in rural areas in the next 20 years.
In
general, information on water quality is variable and dependent on monitoring
systems, with many countries in the process of installing or upgrading them.
Rapid economic growth and industrialization affect water quality in countries
worldwide. Ninety percent of countries in this survey report water pollution as
a serious threat to women and health. Inadequate sewage systems continue to
lead to untreated runoff in many developing countries. In Peru, mine wastes run
into drinking water, dumping heavy metals along the coast. In Russia, 30
percent of groundwater is contaminated by industrial wastes. In Nigeria, 90
percent of industries have no pollution equipment and discharges flow into
rivers and streams. In Cuba and Russia, poor technology, maintenance and
equipment have led to worsening conditions of supply. Women search for clean
water with babies on their backs or with the added burden of pregnancy. In
India, pregnancy complications are reported to result from this task. With
pollution of fresh water sources increasing, women now must go even longer
distances to find water clean enough to meet their needs.
The
health effects of water pollution are especially severe on women and children.
In the Ukraine, 13 percent of the illnesses in women and children are due to
water pollution. In Russia, pollution has led to doubling of bladder and kidney
disorders in pregnant women. In Uzbekistan, prolonged use of water polluted by
pesticides and industry has led to increases in pregnancy complications and
birth defects, and a higher incidence of anemia, and kidney and liver diseases
in women.
In
India, high levels of pesticides, including DDT, have polluted rivers in Delhi
and Agra that are major sources of drinking water. Dangerous levels of arsenic
in groundwater in Bangladesh have affected millions who drink from tube wells.
In Egypt and Morocco, major bodies of water are heavily contaminated with
organochlorine pesticides. Problems in young children due to malnutrition, in
countries like Iran, are sometimes compounded by the health effects of
continued use of contaminated water. In Algeria, typhoid is endemic, mainly
because polluted water mixes with drinking water supplies. Exposure to
pollution in aquatic food products is also harmful for women in countries
throughout the world. In Colombia, mercury from gold mining has contaminated
water supply and threatened fish populations. In the Angke estuary in
Indonesia, mercury in commercial fish far exceed WHO levels for human
consumption. More sustained efforts are needed by groups working with women to
educate and train them about water resource protection, conservation and steps
women can take to protect themselves in the face of water contamination.
Occupational
and Chemical Hazards
The
drive for increased productivity in many countries has led to more and more
women filling jobs in labor-intensive industries. Industrial chemicals and
other toxins in the environment are taking a massive toll on the health of
women around the world, through both occupational and residential exposures.
Eighty-two percent of countries report on occupational health hazards faced by women.
In
China, some large-scale export industries promote themselves as
''environmentally friendly,'' although they still may contribute to problems
through various practices. Other firms blatantly ignore environmental and
health and safety concerns. Employers view young women as "more
compliant" and "less likely to challenge" violations to health
and safety laws in many countries. In Poland, the upper Silesian Industrial
Zone, designated an "ecological disaster area," is characterized by
high cancer and infant mortality rates and lowered birthrates. Advanced
industrial development means exposure to an increasingly complex number of
chemical substances, with little understanding of health impact. In Japan,
studies have shown that workers are exposed to more than 50,000 chemical
substances at various industrial sites. In Cairo, total industrial waste has
nearly doubled in recent years. In the Ogoni region of Nigeria, women have
suffered dramatic losses in food productivity as a result of environmental
devastation in the region from oil exploitation.
Women
also face previously unknown threats to safety and health in the workplace as a
result of exposures to new types of chemicals. Risks to reproductive health
from workplace exposures to chemicals need far more attention and research
worldwide. Chemical exposures and alterations in reproductive behavior have
been recognized in laboratory animals and wildlife while evidence for humans is
less certain. While some known substances such as dioxins and cigarette smoke
threaten reproductive health, analysis of the association of chemical exposures
and adverse reproductive outcomes in humans is reported to be controversial.
Some studies indicate that chemical exposures are associated with infertility,
spontaneous abortion, or reproductive cancer in women. Other studies indicate
that there is no association between chemical exposures and adverse
reproductive outcomes. The mechanism by which chemicals alter reproductive
function in all species is complex and may involve hormonal changes, immune
system threats, and changes at the cellular level or in DNA. Far more research
is needed to clarify the ways in which specific substances affect human
reproduction and by which mechanisms of action.
The
reports in this survey provide numerous examples of the ways in which
reproductive health is threatened through chemical exposures in the workplace.
Forty-four per cent of countries report reproductive health disorders. Many
occupations threaten women's reproductive health - carpet weaving in Iran,
horticulture in Colombia, the shoe industry in Italy, rubber production and
production of chemical fiber carpets in China. Women workers in these sectors
show evidence of complex symptoms including menstrual disorders, stillbirths,
miscarriages or impaired birth weight due to exposures to complex chemical
mixtures on a daily basis.
Many
risks to women in the workforce are still unrecognized, uncharacterized and/or
uncontrolled. In most countries, there is little awareness of the growing complexity
of chemical exposures for women, particularly in rapidly developing industrial
sectors. Women are predominant in the informal sector or work as part-time or
casual workers in many countries. While this may provide them greater
flexibility in terms of juggling domestic responsibilities and tasks related to
childcare, it also means that their activities are not covered by government
regulation and oversight of occupational health and safety. Temporary workers
are also less likely to have health coverage or access to medication. Where
health and safety regulations are in place, resources to enforce them are often
inadequate. In the Ukraine, for example, 87 percent of companies do not meet
government safety norms.
While
ILO conventions and many domestic laws regulate conditions of women's
employment, response to problems of reproductive risks and workplace exposures
has been varied. In Europe laws stipulate that both pregnant women and
soon-to-be fathers are entitled to work that does not expose them to harmful
substances. Italy, Norway, the Netherlands and the U.K. report problems with
implementation of regulations allowing for changes in jobs or work adjustments
for pregnant women (and in some cases soon-to-be fathers). Educational
brochures in the U.S. have been developed to outline occupational reproductive
risks for pregnant women and targeted health monitoring and educational
programs for occupations with reproductive risks have been developed in Iran as
well as guidelines for hazards related to new and expectant mothers, and blood
sampling in Colombia. However, far too many women are still not aware of their
rights in these areas.
Many
countries approach the problem of occupational safety for women by treating men
and women equally and applying the same standards across the board, as stated
in the U.K. government response. NGOs have emphasized the need for more
education and training, research and monitoring of the effects of environmental
pollutants on women's health. They call for women's greater involvement in
decision-making on issues of environment and development to fully reflect
women's needs. Labor protection statutes need to be refined along with greater
cooperation between health care and environmental protection institutions to
reflect sensitivity to women. Labor protection facilities need to be enhanced
rapidly along with increased sensitivity to these issues in trade unions and
female worker associations. Finally, there is a need for more effective
protection of legal rights and interests of workers and strengthening of
oversight mechanisms in law enforcement.
Occupational
health clearly must be put in a perspective of community health, given that
that such a great proportion of women, particularly in developing countries
belong to industrial sectors which are not covered by occupational medicine
legislation, that is the agricultural and informal production sectors. The
medical community as a whole needs more training about occupational risks for
women so that they can identify these risks.
Pesticide
Contamination
The use
of pesticides in agriculture has increased worldwide in response to growing
demands posed by globalization and export-oriented technologies. Women in the
developing world produce half the world's food but exercise little control of
decision-making and land ownership. They are often lowest paid, with the
highest exposure to pesticides that pose clear health risks. Seventy-eight
percent of countries report pesticide contamination as a threat to health. In
Latin American and Caribbean countries like Costa Rica, female agricultural
workers have neurobehavioral deficits, increased lung, cervical cancers and
leukemia. Two-thirds of flower workers in Colombia suffer headaches,
conjunctivitis, rashes and asthma. In Jamaica, there are concerns about
potential health effects on thousands of women in the coffee industry exposed
to endosulfan, now considered an endocrine disrupter. In Eastern European
countries like the Ukraine, women with long term pesticide exposure report high
rates of reproductive health problems including fibromymas and inflammations of
the uterus. In China, pollutants from a state run fertilizer factory resulted
in mental retardation in one third of local villagers and an alarmingly high
number of still births and miscarriages. In Sudan, 22 percent of hospital
stillbirths are linked to pesticide exposures. In Egypt, pesticides were
responsible for one-third of all poisonings.
Pressures
on management to increase productivity lead directly to workers being pushed to
perform beyond safety limits. Of most concern is the fact that most women are
unaware of the adverse effects of pesticide use. Even where products are
labeled, many women cannot or do not read or understand the warnings. Women
agricultural workers generally do not use protective clothing and equipment
because it is unavailable, unsuitable for hot climates or too expensive. In
Indonesia, a substantial number of rural households store pesticides and
pesticide equipment in kitchens and living areas. In South Africa, the problems
of domestic exposure to chemicals is also a source of frequent poisonings.
Women in rural communities clearly need far more education about pesticide
hazards and dangers of other chemicals like kerosene as well as meaningful
incentives for use of protective equipment and implementation of methods of
agriculture which do not rely on chemicals so heavily.
Governments
at the 1992 UN Conference on Environment and Development agreed to promotion of
sustainable agriculture, but set no specific targets for reduction of pesticide
use. Problematic pesticides that persist in the environment, such as DDT, are
receiving new international attention through negotiations to phase out these
chemicals. The benefits of reduced use are clear. Innovative efforts to reduce
pesticide use such as the FAO initiatives in the South East Asia Integrated
Pest Management Program involving training of farmers in reduced pesticide use
has saved the government millions in pesticide subsidies while increasing
farmers' incomes. However, far more needs to be done to tackle the problem,
particularly in many industrialized countries where intensive use of pesticide
remains highest.
Chemical
and Industrial Exposures
Sixty-six
percent of countries report chemical and industrial exposures. Women are
increasingly exposed to chemicals in the home. Women and children sometimes
spend the greatest amount of time in the home, which may place them at greater
risk. Although there are roughly 48,000 industrial chemicals now in use, only a
quarter are documented with toxicity data. New products continue to be placed
on the market without adequate control over safety. Poisonings and burns, along
with low-level, long-term exposures are a problem worldwide. In Nigeria, where
chemical burns were once rare, they are now common among children due to
storage of chemicals in homes by parents involved in soap making. The U.K. and
Germany report on concerns about women's exposures to chemicals such as
perchloroethylene in the home and workplace. Other chemicals of concern are
hormone disrupters such as phthalates used in plastics, brominated flame
retardants used in plastics, carpets and computers and Bisphenol-A used in the
lining of tin cans. In China, new widespread training programs entitled "Women,
Home and the Environment" educate women about day-to-day risks.
In many
countries industries have sprung up in close proximity to residential areas.
Even where the creation of industrial enclaves is subject to land use planning,
industrial sites are often too close to where poor communities live. This
raises environmental justice concerns including class and race discrimination
since non-white and poor communities are most affected by environmental
degradation. Poor women and women of color have the heaviest burden of exposure
and disease and are often those with the least access to formal health care
services.
Women
have emerged as strong community leaders in responding to these threats by
becoming active at the local level. In South Africa, the poorest women have the
greatest exposures to disease and toxins and suffer poor quality water and
sanitation. In the U.S., black women in Cancer Alley, Louisiana, and Bayview
Hunters Point, California, and indigenous and minority women in the Midwest
struggle to mobilize and educate communities about connections between the
environment and their health.
More
efforts are needed to ensure that people can comprehend the nature of the
hazards they face on a continual basis. In Germany, for example, new guidelines
focus on substances with common domestic exposures. Prudent precautionary
principles require that we seek to avoid suspect risks, even where scientific
evidence on these risks is still evolving, in an effort to prevent harm, rather
than to confirm it.
Fifty-two
percent of countries link rising rates of breast and other cancers to
environmental problems. The highest rates of breast cancer are found in
industrialized countries, but the WHO predicts that the number of cancer deaths
will double in most countries over the next 25 years. In the U.S. and Canada,
high rates of breast cancer and activism by grassroots women's groups have
impelled governments to fund new studies to explore environmental links to the
disease. There is increasing evidence that a range of health problems,
including some that specifically relate to women, may have a link to pollution
generated by the industrial sector. Studies are examining ways in which women
are affected through residential and household exposures as well as
occupational links.
Breast
Milk Contamination
Accumulations
of toxins in breast milk are reported in many parts of the world, raising
critical concerns about the safety of breast milk for nursing infants.
Thirty-two percent of countries report breast milk contamination from chemical
exposure. In China, breast milk samples from 35 cities were found to have
traces of DDT five to 10 times higher than permissible limits. While the WHO
tolerable daily intake of dioxin is 1 to 4 pg/kg, nursing infants in the U.S.
receive 35 to 53 pg/kg/day and in Japan 100 to 530 pg/kg/day. In Delhi, a
breast-feeding infant receives 12 times the acceptable limit of DDT. In
Guatemala, pesticide residues in breast milk are reported to be 250 times the
amounts allowed in cow's milk. Inuit women in Canada had concentrations of PCBs
and a metabolite of DDT four times higher and ten times higher for the
pesticide mirex than women in control groups. Studies in Zimbabwe found that
almost all of the breast milk samples taken in some regions showed contamination
with DDT. In parts of Brazil babies consume almost four times the acceptable
level of DDT.
There
is an ongoing debate among public health advocates on breast milk as a
potential source of exposure to toxic substances for nursing infants. Evidence
so far suggests that the dialogue on whether human milk and breast-feeding can
always be unequivocally recommended for women worldwide needs to continue. It
is clear that virtually all mothers carry environmentally derived chemicals in
their bodies. Given that human breast milk is vital to the optimal development
and well being of the infant, and that breast-feeding women also have decreased
risk of breast cancer, the need for continued vigilance in testing and
monitoring of these exposures is clear. Educational efforts are needed to help
policy-makers and women make informed decisions on this issue and better
understand risks.
Air
Pollution
People
living in urban areas are exposed to the combined impact of pollutants from
vehicular traffic, emissions from industrialization and indoor air pollution.
In many cities both in developed countries and the developing world, air
pollutants exceed health standards. Sixty-two percent of countries report that
air pollution is a significant health hazard. Fifty percent report increases in
respiratory ailments. In Russia, the most polluted air is in regions where
effects of mining, metal and oil refining industries are concentrated. More
than 10 percent of air samples exceeded limits on a variety of pollutants. In
the Urals, the synergistic impact of chemicals is causing birth defects,
tumors, malignant blood diseases and diabetes. In the Ukraine, 21 percent of
all illnesses affecting women and children have been linked to air pollution.
In
Tehran, where air pollution exceeds acceptable standards, a variety of public
policy initiatives such as encouraging factories to move to suburbs or
increasing natural gas buses have been tried. However, in some cases, such as
the Netherlands, measures to cut back on air pollution by restricting traffic
add to the problems of already overburdened women who may have to bicycle their
children to work in addition to juggling other domestic and work
responsibilities. In Germany, polls show increasing reluctance to restrict car
use, even for environmental goals. In Eastern Europe, there are concerns about
high levels of usual air contaminants such as sulfur dioxide, carbon monoxide
and nitrogen dioxide, but also for substances such as formaldehyde, and
benzo[a]pyrene classified by the International Agency for Research on Cancer as
known carcinogens.
Fifty
percent of countries report respiratory ailments as a result of air pollution.
In the U.K., government experts found that 12,000 to 24,000 people might die
prematurely as a result of exposure to air pollution. In many developing
countries, respiratory assaults are exacerbated by women's exposures to
domestic pollution from particulates in indoor smoke due to cooking and living
in poorly ventilated homes where coal and paraffin are burned. In Turkey,
indoor pollutants, 1,000 times more likely to reach the lungs than outdoor
sources, combine with industrial exposures to cause higher levels of
respiratory infections in women.
In the
developed world, there is a dramatic increase in asthma. Often thought to be a
disease of childhood, asthma has a clear impact on millions of adults, women in
particular. In the U.S. for example, death rates from asthma are 59 percent for
women and only 34 percent for men.
Smoking
as a serious problem for young girls emerges in many countries, including the
U.K. and New Zealand. In Norway, the proportion of female smokers was
previously higher for women than men, but has now begun to equalize. Additional
educational efforts are needed to address smoking in pregnant girls. Although a
variety of countries have strengthened smoking regulations in public places,
they are often hard to enforce.
Sewage
and Solid Waste
Sixty-two
percent of countries report that sewage and solid waste disposal causes serious
health problems. The Programme of Action calls on developed countries to take
the lead in achieving sustainable consumption patterns and effective waste
management. The link between women's health and poor sanitation and waste
disposal is clear. Without basic services, particularly in informal squatter
communities and rural areas, human excreta and garbage accumulate, contributing
to the spread of disease. Flies and hands contaminated with fecal matter help
with transmission. Thirty-two percent of countries report that waterborne diseases
are major environmental health problems. Diarrheal diseases, schistosomiasis
and trachoma are linked to lack of hygiene.
Solid
waste also attracts mosquitoes that transmit malaria. In Nicaragua, garbage
disposal is largely unregulated and only 13 percent of dumps in that country
are certified as sanitary. In South Africa, in informal settlements in the
Western Cape, wetlands are used for human waste disposal, resulting in
problematic odors and community disease. Solid waste is scattered into numerous
open-air sites.
Emissions
from solid waste and medical incinerators in Japan and the U.S. have led to
public exposure to dioxin, which has accumulated in the food chain. Dioxin is a
known human carcinogen that has been linked to birth defects, decreased
fertility, immune system suppression and other hormonal dysfunction. One study
in Japan found that more than 25 percent of marine products were found to have
trace levels of dioxin. The presence of dioxin in women's breast milk, as
revealed by a health ministry report, was strong enough to stir a public debate
in Japan last summer. The report quotes a minister as saying that breast-fed
Japanese babies are on the average "taking about six times the daily
tolerable amount of dioxins." However, the minister was uncertain about
how dioxin affected the body.
In the
U.S. and other industrialized countries, exposure to dioxin in adults is near
levels at which WHO warns that subtle adverse neurological and endocrine
effects may already be occurring. In the U.S. population of 260 million for
example, a range of 111 to 1,114 cases of cancer may be directly linked to
dioxin exposure from the food chain. A nursing infant in the U.S. and other
industrialized countries may consume an average of 35-53 pg Teq/kg/day in its
first year of life. The current U.S. Environmental Protection Authority
virtually safe dose is 0.006 pg TCDD/kg/day. These findings make more urgent
the WHO recommendation that every effort should be made to reduce exposures to
the lowest possible levels.
Lead
Pollution
Lead
exposure is a serious problem for women and children. While the impact of lead
on children is well known, the special vulnerability of women, particularly
pregnant women, has long been suspected. As a result, in some places, women have
been excluded from many jobs involving lead exposure in previous years. But
occupational exposures to lead remain a problem for women workers in many
countries. Studies have tried to determine the degree of gender-related
differences in susceptibility.
Many
parts of the world - 48 percent of countries in this survey - report high
levels of lead exposure. In Poland, emissions of lead in the countries most
industrialized and urbanized areas are leading to severe health effects.
Studies show that seven percent of children in some areas have blood lead above
levels that would affect mental development. Communities can also be
unknowingly exposed to lead from battery manufacture plants and formal and
informal lead smelters, as documented in Jamaica.
Exposure
to heavy metals such as cadmium, lead and mercury is also a concern because of
accumulations in breast milk. In a number of Egyptian cities including
Alexandria and Cairo, lead levels in breast milk were found to be significantly
higher than permissible limits. More research is required to better understand
the impact of low-level exposure to heavy metals transmitted through breast
milk.
Significant
efforts are underway worldwide to reduce lead in gasoline, but lead in paint
and water piping is still a worrying problem. Housing conditions, smoking
status and high consumption of canned foods may also be predictors for lead
exposures. In Nigeria, water bodies and springs have become contaminated with
lead from mines and cooking salts collected by women are a source of
contamination. A popular eye cosmetic used there also contains high lead
levels. In Poland, a pre-requisite for effective prevention of occupational
lead poisoning is inventory of workplaces where lead occurs and monitoring of
lead concentrations in the air. Egypt has initiated efforts to relocate public
and private lead smelters. Special campaigns on lead exposure need to be
directed at pregnant women and mothers of small children, in addition to
workplace efforts in lead industries.
Hazardous
Waste and Radiation
More
than a quarter of countries report hazardous waste and radiation are growing
health concerns. Hazardous waste sites, illegal dumps, landfill sites and
incinerators are often located near informal settlements, in proximity to poor,
minority and indigenous communities. The U.S. Environmental Protection Agency
has formally recognized that health effects associated with hazardous waste
sites include birth defects, cardiac disorders, changes in pulmonary function,
impact on the immune system, infertility and increases in chronic lymphocytic
leukemia. A Europe-wide study published by the European Commission found that
women whose fetuses were malformed were more likely to have lived close to
landfills than those whose babies were normal. This has raised new concerns in
countries like Great Britain, where studies have been launched to examine local
impact.
The
devastating environmental effects of military activity and nuclear weapons and
energy production result in enormous human costs, even in situations of peace.
Black Mesa in the U.S., Chernobyl in the Ukraine and Chelyabinsk in Russia are
places where environmental devastation from uranium mining, nuclear energy and
nuclear weapons production has taken a tremendous toll on women's health. In
Chelyabinsk, where radiation is twice that of Chernobyl due to a nuclear
accident in 1957, cancer incidence has since gone up by 21 percent and birth
defects by 25 percent. Half the population of childbearing age is sterile.
Testimonies from the Tuareg in Algeria speak of the effects of French nuclear
testing in the 1960s now being seen on entire tribes, including sterility among
women and increased cancers. While compensation for damage from nuclear testing
and mapping of health effects has occurred in some regions such as Southern
Australia, most countries have no effective response.
Conclusions
Since
ICPD, awareness has grown of the links between economic growth and
environmental degradation. But development strategies are still not being
revamped to incorporate an environmental agenda. In some countries, new laws
and initiatives aim at increasing environmental protection. New international
agreements to regulate use of problematic chemicals include the Rotterdam Convention
signed in 1998 regulating trade in some hazardous chemicals and pesticides and
other 1998 protocols on heavy metals and sulfur emissions developed as part of
the UN Economic Commission for Europe Convention on Long Range Transboundary
Air Pollution. Negotiations are underway in the International Negotiating
Committee on Persistent Organic Pollutants. International efforts have also
begun to develop systems to collect and disseminate data on environmental
releases and transfers of toxic chemicals from industrial facilities as part of
the creation of Pollutant Release and Transfer Registers. In addition, NGOs
have been innovative, despite limited resources, in developing programs and
strategies to address environmental health needs.
The
Programme of Action recommends measures to enhance the role of relevant groups,
particularly women, in all levels of population and environmental
decision-making, increased research on linkages between environment, population
and human health and additional efforts to promote public understanding of
these linkages. But there is still not enough recognition among governments of
the effects of environmental degradation on health. Environmental groups and
health organizations often do not work in tandem on environmental issues
critical to health. Little has been done to disseminate information on
environmental health risks to the public at large.
Yet, it
is often public pressure as a result of grassroots activism that has created
momentum for responsive action or legislation, as in efforts to reduce lead
exposures in gasoline, for example. In general, governments' fears of alarming
the public or creating new problems for the economy and the industrial sector
have blocked wider progress. Prudent precautionary principles call for efforts
to prevent harm by avoiding suspect risks, even where scientific evidence on
these risks is still evolving. Instead, official response continues to focus on
those few risks where the human evidence is overwhelming.
Five
years after ICPD, there have been important initiatives to advance the
Programme of Action in countries around the world considerable economic
constraints. The reports in this survey show that incremental progress toward
the Cairo goals is possible given political will and the presence of an
informed and active civil society pushing for change. Reproductive health is
now part of official lexicon, policies and programs. The emergence of new
partnerships between governments, NGOs, international actors and the private
sector has enabled creative collaborations and greater civil society
participation and promoted rights-based approaches.
In the
majority of countries, NGOs have been instrumental in bringing about key
legislative changes and innovative programs through strategic alliances with
governments and non-state actors. They have also secured recognition in
important policy arenas of the impact of economic policies and environmental
conditions on women's health and access to services. Governments at the
International Forum for the Five-Year Review of the Programme of Action, held
at The Hague, February 8-12, 1999, acknowledged that globalization of the
economy and privatization of social and health sectors have deepened poverty
and reduced access to social and health services. Women's health advocates have
also won recognition of the fact that financial viability of public health
systems sought through health sector reforms can erode universal access to
quality and comprehensive reproductive health services. Above all, realization
of the goals of Cairo and Beijing is intrinsically linked to eradication of
poverty and elimination of unsustainable patterns of production and
consumption. Reducing the debt burden of the world's poorest countries and
ensuring that structural adjustment and other economic reforms are responsive
to gender and environmental concerns are urgent priorities.
Most
importantly, the profound human crisis caused by the unraveling of the miracle
economies in Asia, long upheld by the International Monetary Fund and the World
Bank as stellar successes of the Washington consensus, has led to rethinking in
the Bretton Woods institutions of their liberalization prescriptives. For women
activists, the new climate of caution and introspection opens up critical space
for renegotiating neo-liberal policies that have long ignored gender
implications. Recent developments and the five-year process of the Cairo
Programme of Action have borne out what women have said for the last two
decades. Market-driven policies and other macro-economic issues can no longer
be kept off the table when sustainable development, women's rights, the
environment and health are discussed.