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PASSPORT TO DIGNITY

 

CHAPTER VII

CRITICAL AREA OF CONCERN C: WOMEN AND HEALTH


… from the Human Rights Instruments

Everyone has the right to rest and leisure, including reasonable limitation of working hours and periodic holidays with pay.

(Universal Declaration of Human Rights, Article 24)

Everyone has the right to seek and to enjoy in other countries asylum from persecution.

(Universal Declaration of Human Rights, Article 14)

25.(1) Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

(Universal Declaration of Human Rights, Article 25)

1. The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

2. The steps to be taken by the States Parties to the present Covenant to achieve the full realization of this right shall include those necessary for:

(a)The provision for the reduction of the still-birth-rate and of infant mortality and for the healthy development of the child…

(c)The prevention, treatment and control of epidemic, endemic, occupational and other diseases;

(d)The creation of conditions which would assure to all medical service and medical attention in the event of sickness.

(International Covenant on Economic, Social and Cultural Rights, Part III, Article 12)

11.(1) States Parties shall take all appropriate measures to eliminate discrimination against women in the field of employment in order to ensure, on a basis of equality of men and women, the same rights, in particular…

(f) The right to protection of health and to safety in working conditions, including the safeguarding of the function of reproduction.

(Convention on the Elimination of All Forms of Discrimination against Women, Part III, Article 11)

12.(1) States Parties shall take all appropriate measures to eliminate discrimination against women in the field of health care in order to ensure, on a basis of equality of men and women, access to health care services, including those related to family planning.

12.(2) Notwithstanding the provisions of paragraph I of this article, States Parties shall ensure to women appropriate services in connection with pregnancy, confinement and the post-natal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation.

(Convention on the Elimination of All Forms of Discrimination against Women, Part III, Article 12)

Women have different and unequal access to and use of basic health resources, including primary health services for the prevention and treatment of childhood diseases, malnutrition, anemia, diarrheal diseases, communicable diseases, malaria and other tropical diseases and tuberculosis, among others. Women also have different and unequal opportunities for the protection, promotion and maintenance of their health. In many developing countries, the lack of emergency obstetric services is also of particular concern. Health policies and programs often perpetuate gender stereotypes and fail to consider socio-economic disparities and other differences among women and may not fully take account of the lack of autonomy of women regarding their health. Women's health is also affected by gender bias in the health system and by the provision of inadequate and inappropriate medical services to women.

(Beijing Platform for Action, Chap IV, para. 90)

The human rights of women include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence. Equal relationships between women and men in matters of sexual relations and reproduction, including full respect for the integrity of the person, require mutual respect, consent and shared responsibility for sexual behavior and its consequences.

(Beijing Platform for Action, Chap. IV, para. 96)



REFLECTING ON THE PRINCIPLES AND STANDARDS

In your community/country is health generally recognized as a human right?

is women’s health recognized as a human right?

Is women’s access to health care equal to that of men?

Which aspects of women’s health receive attention in your country/community?

Where do women go when they are sick? What kinds of institutions are available to them?

Which movements, organizations or institutions in your community deal with the health needs of women?

Women's multiple responsibilities at work, home and in the family often prevent them from enjoying the right to rest and leisure necessary to maintain good physical and mental health. Should there be human rights standards to limit women’s workload in the home as well as in the work place?

If so, which standards might be invoked ? (Review ICESCR and the Convention on the Elimination of All Forms of Discrimination against Women [CEDAW]).

Are reproductive health care services, including contraception and abortion, available to women who need them?

Do all women in your country have full control over their own sexuality, spacing of pregnancies, number of children and reproductive health? What factors influence this control?

What kind of health coverage is available in your country and local community?

Are there gaps in the coverage provided? What are they?What are the gaps in women’s health coverage?

Has your country they taken the steps enumerated in Article 12 of the International Covenant on Economic, Social and Rights (ICESCR)?

What place does health occupy in the budget of your country or community? Is it adequate?

What kind of insurance is provided in your country?

How do women get access to health services?

Are reproductive health care services, including contraception and abortion, available to women who need them?

Do women in your country have full control over their own sexuality, spacing of pregnancies, number of children? What factors influence their control?

What kind of reproductive health care services are available to women?

 

Health Care Is a Human Right

Very few countries have fully integrated the concept of health as a human right and provided adequate health care services to all of their citizens, men as well as women. Health in general and women’s health care in particular are the object of contradictory approaches.

It is increasingly recognized that access to health care can be strongly gender differentiated. Evidence suggests that in many places, men have better access to higher level curative care, even though women are more likely to benefit from preventive care during their reproductive years. Meanwhile, older women’s health needs are often neglected.

But gender issues are not just about access or about the mix of services available. They are also directly related to pervasive gender inequality. In some societies, men play a determining role in decisions over when and where to seek curative care. Links between women’s morbidity and mortality and gendered power relations are evident in the case of maternal mortality and, most starkly, of gender-based violence. The HIV-AIDS pandemic has forced sexual health onto the policy agenda, albeit a rather limited notion of sexual health, and the inclusion of women’s exposure and prognosis has been haphazard at best. Pregnancy and childbirth have given rise to much protective legislation, other aspects of women’s health are often surrounded with ignorance and denial. In recent years, breast cancer has received much attention but women’s congestive heart failure which is much more widespread, is generally overlooked. The connection between bad nutrition, early age of first pregnancy and the occurrence of fistula , a serious and potentially life-crippling condition is generally neglected. And there is a continued lack of appropriate measures to tackle cervical cancer, the main cancer affecting young women.

The United States provides a good example of these contradictions: for example, health and hygiene are major public issues; nutrition is surrounded by impressive governmental regulations; the country is very proud of the high level of medical technology available for sick persons. Yet only a minority are sufficiently insured to enjoy the higher levels of health care on which the country prides itself or even to cover their basic health needs; the culture as a whole has somewhat haphazard attitudes about work safety or environmental health; many women’s health is affected by poverty, lack of information and sexist attitudes; women’s reproductive rights are both loudly proclaimed in the media and denied in actual life by a number of states.

Women’s multiple social roles, especially their roles as caregivers, make their health essential to the well-being of society, and that aspect of women’s health has increasingly been recognized in the twentieth century, but women’s needs are unlikely to be met in the absence of a general commitment to health care for all citizens as a human right. Many medical professionals have come to believe that the issue of health care should be addressed within the framework of universal human rights.

Unfortunately, another current trend has been a de-emphasis on public health on account of its costs. Functional healthcare institutions are being scaled down or even eliminated. This represents a drastic, potentially catastrophic, reversal of almost one hundred years of progress in public attitudes about health and illness. This is made worse yet by the increasing pollution of environments, diminishing nutritional value of food, and growing levels of stress, leading to diminished immune systems. In this context, it becomes ever more urgent to face the implications of the human right to health.

In 1992, the Science and Human Rights Program of the American Association for the Advancement of Science (AAAS) initiated a project exploring the implications of recognizing a right to a basic and adequate standard of health care and assessing the benefits and problems in doing so...

For the right to health care to be secure and meaningful requires that an entitlement be translated into specific obligations and commitments consistent with available resources. The AAAS Science and Human Rights project has focused on this task [and has developed] a kind of human rights report- card both to shape health care reforms and to evaluate whether specific proposals are consistent with human rights requirements.

The project proposes recognition of a right to a basic and adequate standard of health care consistent with society’s level of resources. In an advanced industrialized country like the United States, it is appropriate that all citizens and residents be guaranteed a comprehensive standard of health care. The right to basic health care should be understood as a component of a broader effort to protect and improve the public's health.

A human rights approach acknowledges that all persons, without regard to their purchasing power, social status, or personal merit, are entitled to basic and adequate health care. It confers a sensitivity to and a priority on meeting the needs of the groups most disadvantaged...

The concrete requirements and implications of affirming a right to a basic and adequate standard of health care are the following:

1) A right to health care mandates that a basic and adequate health care entitlement be guaranteed to all citizens and residents.

(2) Because a human right is a universal entitlement, a rights approach would emphasize the equality of all persons and their inherent right to health care as the framework for health care reform.

(3) By employing rights language, the provision of health care would be understood as a fundamental important social good to be treated differently from other goals.

(4) A human rights approach focuses particularly on the needs of the most disadvantaged and vulnerable communities.

(5) By establishing clear individual entitlements to health care, a rights approach would empower individuals and groups to assert their claims.

(6) A meaningful and secure right requires that health care be affordable and publicly financed.

(7) A human rights approach underscores the importance of meaningful public participation in setting priorities and shaping health care reform.

(8) A rights formulation translates into a series of obligations on the part of the federal and state government.

(9) A rights approach provides potential recourse for those who experience violations.

(10) The rights approach advocated in this study balances individual needs with the common good thereby making the viability and effectiveness of the health care system a shared concern and responsibility.

(The Right to Health Care, Project Summary Report, Audrey Chapman, Ph.D. Director, Science and Human Rights Program, American Association for the Advancement of Science. June, 1993.)

 

IDENTIFYING PROBLEMS

Make a list of the health rights recognized and observed in your country. Which of women’s health needs are provided for? which, in your own experience, are neglected?

Are the maternal needs and reproductive rights of women in your community adequately dealt with?

Are women regularly screened for cervical and breast cancer?

Are sexually transmitted infections (STD’s) and HIV-AIDS recognized as women’s issues in your country?

What is the status of domestic violence as a public health problem?

What is the status of rape as a public health problem?

How easy is it for women to have access to preventive medicine?

Do you think doctors and nurses are equipped to think of health as a human right?

 

Beyond Population Control: changing perspectives on gender and health

For most of the past century, population control has been an important theme in public discussions; it has been the object of much state regulation, sometimes aimed at slowing down population growth, sometimes aimed at encouraging women to bear more children. The prevention of sexually transmitted diseases also has given rise to a vast literature.

But it wasn’t until the world conferences of Cairo and Beijing that concepts of reproductive rights and sexual health, became an integral part of a general right to health. The international women’s movement has played a key role in this shift of debates and policy towards a gender- and rights-based approach to sexual and reproductive health.

The international women's health movement, which started in the late 1970s and early 1980s, has challenged the rationale on which population policies have been based, namely, that population control in the social interest has precedence over individual well-being and individual rights (...) (The movement ) strongly criticized the prevailing emphasis on narrowly construed "family planning programs" (generally equated with delivery of modern contraceptives and sterilization to married women) as the main way to achieve fertility reduction. It has also questioned the safety of modern contraceptive technologies both intrinsically and as actually delivered, the poor quality of services, the failure of governments to address women's health and empowerment more broadly, and the economic policies that jeopardize social services and promote growth over human welfare. .

[...]

The basic message of the women's health agenda is clear: access to quality health services -- particularly reproductive health services that include safe and effective contraception and abortion -- and respect for reproductive rights are fundamental demands from women worldwide. Most women in the movement agree that the design, implementation, and evaluation of these services should be shaped by a concern for reproductive health and rights, not by demographic objectives, and that policies and programs must treat women as their subjects, not their objects... ensure the broadest possible choice of fertility regulation methods - not only modern methods generally asserted to be most effective, but also barrier methods and male methods -- and safe abortion. These programs should also provide screening and treatment for sexually transmitted diseases, including HIV, and other reproductive health services. Additionally, women have highlighted the need to address sexuality.

[...]

Another fundamental premise of the movement is that women's health and empowerment are goals in their own right, not means to reduce fertility.

( excerpted from Garcia-Moreno, Claudia and Amparo Claro, Population and Ethics: Expanding the Moral Space, Chapter 4 in Population Policies Reconsidered Boston: Harvard School of Public Health (1994), pp. 15-26. http://www.hsph.harvard.edu/rt21/globalism/CLARO.html 


The Cairo Programme and Interrelated ‘Health Rights’

The Cairo Programme uses the language and principles of human rights to add meaning to specific human rights. As human rights laws are applied more vigorously to reproductive interests, a variety of ways of applying them will emerge to advance reproductive interests. Which human rights are invoked, or how they shown to have been violated, depends on the particular facts of an alleged violation, and on the underlying causes of reproductive ill health. The list below is a selection of some of the key rights, certainly not an exhaustive list, which may be developed to advance reproductive interests:

Life and Survival: The Cairo Programme recognizes that women's survival of pregnancy is an issue of women being "equal in dignity and right. This right can clearly be applied to state obligations, for example, to reduce maternal mortality. In order for states to effectively meet their obligations to reduce maternal mortality, strategies must address the complex causes of maternal mortality, which include lack of trained birth attendants, lack of effective means of birth spacing and fertility control, unsafe abortion and disparities between rich and poor countries.

Liberty and Security of Person: States should apply this right to protect women against violations of this human rights which include female genital mutilation, government regulation of population size, such as compelled sterilization and abortion, and criminal sanctions against contraception, voluntary sterilization and abortion. Women’s rights to have informed free choice in family planning programmes also form a part of this human right. Finally, governments must apply the right to liberty and security in order to identify, condemn and redress violations of the right to freedom from torture and from inhuman and degrading treatment, which include sexual torture, involuntary disappearance, sexual slavery, rape, sexual abuse and forced pregnancy. The call for, resulting from the ACPD regional consultation, clear recognition that rape is a deliberate act of aggression and that women who have been raped must have access to services required for their healing, including abortion if so desired, is also a necessary step towards implementing this human right.

Highest Attainable Standard of Health: This right incorporates state obligations to provide and maintain affordable, accessible and acceptable services throughout the life cycle, which are based upon gender sensitive standards for delivery of quality services. This should also include an obligation to encouraging and supporting choice in health services (i.e. contraception, midwives, breastfeeding etc.). States must implement their agreement in the Cairo Programme to provide, through primary health care services, reproductive health to all individuals of appropriate ages as soon as possible, which will include family planning services, universal access to a full range of safe and reliable family planning methods and to related reproductive health services which are not against the law and programmes to prevent STDs including HIV/AIDS and to provide services to treat and counsel those who are afflicted. Finally, the recommendation arising from the ACPD regional consultation that strategies must be holistic (i.e. ensure access to complementary medicine, medical and STD supplies, safe workplaces, clean water etc) and address the social determinants of health, (which include status of women, class, early marriage, nutrition, and access to education and employment) further informs this right.

The Benefits of Scientific Progress: This right includes state obligations to give high priority to reproductive health research, including: affordable access to antiprogestins for non-surgical abortion or to emergency contraception; access to new male contraceptives; HIV infection and other STDs in women; women-controlled methods of protection; and on male and female attitudes and practices. It similarly requires action-oriented research on affordable methods, controlled by women, to prevent HIV and other STDs, on strategies empowering women to protect themselves from STDs, including HIV/AIDS, and on methods of care, support and treatment of women, ensuring their involvement in all aspects of such research.

Receiving and Imparting Information: This right can strengthen state obligations to remove legal, medical, clinical and regulatory barriers to reproductive health information. Clearly, the Cairo Programme called for state action on this issue; nonetheless, it remains a criminal offense in many countries.

Education: Research has consistently shown that women's education strongly influences improved reproductive health, including infant survival and healthy growth of children. This human right supports state obligations to fund and implement strategic programmes which: improve women’s education and literacy levels; ensure access to universal primary education; eliminate all barriers that impede the schooling of married and/or pregnant girls and young mothers; and address adolescent sexuality through quality educational programs in sexual and reproductive health and provide contraceptive counselling and services, including services related to STDs. The recommendation arising from the ACPD regional consultation that there be national standards and enforcement mechanisms for reproductive and sexual health education in schools is also a key factor in meeting state obligations.

Family and Private Life: This right includes state obligations to provide related information, education and services to protect the founding of families; generate social support for the enforcement of laws on the minimum age of marriage, in particular by providing educational and employment alternatives to premature marriage; and to prevent or redress public officials' intrusions to ensure women's autonomous and confidential choice in reproductive matters.

Non-discrimination: There are clear state obligations to remedy the lack of adequate and appropriate services for many groups who have traditionally been disempowered. Strategies that are aimed at meeting the special needs of these groups are imperative. Some of the recommendations that came out of the ACPD regional consultation include calls for strategies to focus on culturally sensitive reproductive health information and services as well as clear action on meeting the Cairo on indigenous sexual and reproductive health. Some examples of how the right to non-discrimination applies to reproductive health (not an exhaustive list of relevant grounds) are as follows:

1.Sex: States must take immediate steps to meet their commitments to eliminate all forms of discrimination against the girl child and the resulting effects of such discrimination such as female infanticide and prenatal sex selection. This right also include state obligations to implement strategies designed to eliminate violence or abuse against women (including refugee women who are in danger of sexual violence) and support to women who are in abusive situations. The recommendation, arising from the ACPD regional consultation, that Canada must promote the enactment of legislation domestically and in other countries to benefit women in areas like marriage and divorce laws (including raising the legal marriage age), inheritance and property law, reproductive rights, violence, and education is also key to effecting this human right.

2.Age: Often adolescents are not provided with adequate access to reproductive health as adults, nor are programmes tailored to meet their needs, simply because of their young age. Given the high rates, domestically and internationally, of adolescent unmarried pregnancy states must immediately take steps to remove regulatory and social barriers to reproductive health education, information, confidential counselling and care for adolescents.

3.Disability: Addressing disability discrimination means that states must take steps to provide quality reproductive health care that meet the special needs the disabled. Strategies should take into account, as is suggested in one of the recommendations from the ACPD regional consultation, the unique sexual and reproductive health needs of people with disabilities, their caregivers and intimate partners. Furthermore, there must be implementation of programmes that are aimed towards eliminating discrimination against persons infected with HIV and their families; strengthening services to detect HIV infection, ensuring confidentiality, and designing special programmes to provide care and the necessary emotional support to men and women affected by AIDS and to counsel their families and near relations.

Reproductive rights and self-determination will mean very little to the well being of women and men if national, regional and international human rights instruments are not effectively used to ensure government compliance of their commitments made in Cairo and Beijing. These instruments must be used to hold governments accountable, legally and politically, for violations if reproductive rights are to be advanced beyond Cairo and Beijing.


The Global Women's Health Movement

The First International Women and Health Meeting was convened in the late 1970s by European and North American women; growing numbers of Southern women have attended the six subsequent meetings. These meetings have been particularly important in fostering debate on a wide variety of issues and in uniting the movement into a political force.

In a review of the potential of international networking to assure women’s human rights, Rebecca Cook reported the following from Colombia. The informant, Dr. Maria Isabel Plata, postulated that this new initiative might encourage similar initiatives in other countries to comply with the CEDAW.

 

Maria Isabel Plata, of Profamilia, Bogota, Colombia, explained how women's groups in Columbia used the Women's Convention [CEDAW[ to promote equality and reproductive health, observing that "the moment we used an international treaty, the government saw that our claims were legitimate and began to take us seriously." The Colombian women's movement lobbied for incorporation of the principles of the Women's Convention into the 1991 Constitution, and within that context sought new laws and policies, for the promotion of women's reproductive health. As a result, the Women's Convention became a part of Colombian law (The Colombian Presidential Decree No. 1398 of July 1990: Colombia Law 51, 1981) and some of its principles were adopted into the new Constitution, including a provision on the right to decide freely and responsibly the number of one's children.

Maria Isabel Plata explained that the Ministry of Public Health has interpreted the Women's Convention to establish a gender perspective in their health policies that considers "the social discrimination of women an element which contributes to the ill-health of women." A new Ministerial resolution orders all health institutions to ensure women the right to decide all issues that affect their health, their life, and their sexuality, and guarantees rights " to information and orientation to allow the exercise of free, gratifying, responsible sexuality which is not necessarily tied to maternity." The new policy requires provision of a full range of reproductive health services, including infertility services, safe and effective contraception, integrated treatment for incomplete abortion, and treatment for menopausal women. The policy emphasizes the need for special attention to women at risk, such as adolescents and victims of violence.

(Rebecca Cook, Women's International Human Rights Law: The Way Forward, in – Human Rights Quarterly, Vol.15, No. 2. May 1993.)

 

Muslim Women’s Organizations Advocacy for Family Planning in Medan, Indonesia

Like Catholicism and Orthodox Judaism, Islam has been traditionally unsupportive towards women’s control of their fertility. Hadja Chalidah Hassan recently described the family planning advocacy of three well-established Muslim women's organizations in Medan, the capital of North Sumatra, a multicultural city where Islam is the religion of the majority of the population. Despite some differences, the three organizations--Aisyiah, Muslimat nahdlatul Ulama, and Muslimat Al-Washliyah--share the same goal: to empower Muslim women in various fields of life and prove that Islam, as a religion, does not hinder women from working and performing many kinds of suitable activities. The three organizations made considerable contributions to change the community's way of thinking about and behaving toward family planning programs in Medan. The three organizations all originating early in the 20th century, were rooted in a deep concern towards the reality of women’s subordination and marginalization. The patriarchal culture and poor understanding of Islamic principles had caused the emergence of a common perception among the community that Indonesian Muslim women were weak, foolish and emotional creatures unsuiteds for leadership. This motivated and roused the founders of the Indonesian Muslim women’s groups to redefine themselves, to reformulate their actual positions among men, their fields, rights, and their role in building nation and umat (the community of Believers).

(...) When the government began to promote family planning programs, the majority of Indonesian Muslims opposed them. Opposition was based on religious, political, and cultural grounds. From the religious point of view, family planning was perceived as contrary to Islamic doctrines. Politically, government policy to control population growth was regarded as a Christian missionary program to reduce the Muslim population and "subjugate" Islam. Culturally, family planning was traditionally considered unthinkable in a family that did not yet have a son. Taken together, these perceptions seriously inhibited family planning. The challenge for these organizations was to find an approach that would acknowledge women’s and their families’ perceptions without seeming to question Islam’s rootedness in Allah’s sovereignty. In this context, the general acceptable principle for birth control was to ensure that reproduction was healthy for the mother and the family's well-being. Many did not accept vasectomy and tubal ligation because they interfered with the integrity of the human body created by Allah. Finally, some members of the organizations objected to the application of contraceptive devices by male doctors.

The three organizations’ approach involved weekly meetings, regular bulletins and magazines, training sessions, the establishment of educational institutions (particularly Kindergarten), and the organization of health clinics.

Their success comes from the ingenious use of traditional concepts. One was the obligation of the faithful to work diligently. In this context, Muslim women of Medan proved that they could apply the Islamic concept through the activities of family planning advocacy while at the same time fully paying their roles as housewives, mothers and members of the community. They showed that Islam is no barrier to women doing work outside the house, as misunderstood in general by Western people.

Change is gradual and continuous. Change, particularly in conduct and understanding religious principles, cannot be achieved in a very short time. In this context, as stated by the head of Muslimat NU, the key success of Rasulullah, peace be on him, in social change depends on a gradual and continuous process. This avoids psychological and cultural shocks in the community. Although they needed a very long time to complete their work, the Muslim women involved in the three organizations could demonstrate positive progress in family planning.

(...)

The use of Islamic words for socialization and family planning advocacy was the key to the progress of `Aisyiah, Muslimat NU and Muslimat Al-Washliyah in Medan...The three organizations used the primary sources of Islam, al-Qur'an and Hadits, to explain family planning to the Muslim community in a rational and functional way. They reported the following obstacles and difficulties to family planning advocacy.

Lack of qualified human resources. The three Muslim women’s organizations still lack qualified human resources to promote their family planning programs. Some members, particularly in Muslimat NU and Al-Washliyah, refuse programs under the treatment of male doctors. This is why the clinics under the management of the three organizations worked hard to provide the mothers with female doctors. Nevertheless, there are very few female doctors who are experts in family planning. This is of course the biggest obstacle the three Muslim women organizations face.

Lack of funds. The three organizations still do not have enough funds to promote their programs. The amount of money they get from the government and foreign countries is not adequate. Indeed, the organizations have not received government funds for family planning advocacy since the beginning of the monetary crisis in Indonesia in 1997 and have to rely on donations from wealthier members of the community.

Insufficient clinics. The rising number of LSM (Non Government Organizations) and clinics dealing with family planning advocacy helps provide the community with family planning services. In general, private clinics in Medan are managed directly by specialists with complete and advanced techniques. In the future, the advocacy clinics of the three organizations continue to expect that they will have professional and qualified staff with complete and modern techniques sustaining the programs of family planning advocacy.

Diversity of community knowledge. Differences in community education levels have led to different interpretations of the verses of al-Qur'an and the Prophet's Hadits, particularly as regards family planning. The three organizations worked long and hard to change incorrect understandings and interpretations in the community.

Despite continued resistance, the three Muslim women’s organizations have become a united power to promote significant social change and improve religious understanding toward family planning. In other words, they have become agents of social change and advocacy; consequently family planning is not simply accepted but expected. Moreover their success indicates that they have participated in the local government's development programs to make national development in Indonesia a reality.

(Hadja Chalidjah Hasan The Role Of Muslim Women's Organizations In Family Planning Advocacy In Medan The Foundation for Empowerment of Muslim Women Medan, Indonesia, 2000

online http://www.philanthropy.org/GN/KEN/gntext/civilrights_womens_agency_hasan.htm )


Reproductive Rights

People often forget these days that reproductive control involves also ensuring women’s ability to bear children , and thus the issue of safe fertility control technologies is a very important one. One prime example of the damage caused to women’s health by irresponsible experimentation with new technologies was presented by the story of the Dalkon Shield. The following story is that of one African-American woman whose reproductive organs were irreparably damaged by the Dalkon Shield and irresponsible practices of health care agencies. In her case, this led to her active involvement in human rights activism, where she has became a major player.

This is actually a story about victory though; even though up until that time I had been a victim. Fortunately, I was so angry at what had happened to me that I immediately found a lawyer, and I became the first black woman to sue the maker of the Dalkon Shield., A.H. Robbins. It turned out that they knew more than five years before mine was inserted that it was unsafe, yet they were still making it freely available to women, like me, who got their health care through public family planning clinics. It also turned out that the hospital I was treated at knew that the Dalkon Shield was unsafe. But because it was a teaching hospital, they wanted their students to see what would happen to a Dalkon Shield patient who did not have it removed for six months. So I sued them, too.

I actually made a commitment in that moment that I would make sure that all the things that had happened to me would never ever, ever happen to another black woman in America without somebody like me being there to fight for her. At the time these things were happening to me, my parents didn't understand, my community didn't understand, and the women's movement such as it was at the time didn't understand. They didn't understand that we who were black, who were poor, who were women of color, had a special kind of human rights abuse that America saved just for us, and that we had to be vigilant in fighting to protect our lives as anything because the rest of the world simply did not care. This doctor told me that what happened to me was a mistake, but as I pursue the fight to get rid to his medical license, I'm going to convince somebody that licensing that man was their real mistake.

(Center for Women's Global Leadership. The Testimony of Loretta Ross at NGO Forum at the U.N. International Conference on Population and Development. From Vienna to Beijing: the Cairo Hearing on Reproductive Health and Human Rights. 1994.)

Klinik Fanm : Health and Human Rights for Peasant Women in Haiti

Health problems are often the avenue through which women find human rights work , Mouveman Peyizon Papay (MPP), Lower Central Plateau, Haiti MPP is Haiti's oldest peasant movement. The women of the MPP in this very poor region of the country are looking at the complete breakdown of health care by establishing mobile women's health teams. Solidarite Fanm Ayisyen (SOFA), a local democracy movement Port au Prince Haiti was formed to "create a space where women, especially poor women, can meet and develop skills," The group carries out literacy classes, small business training, education programs for rural and urban women on reproductive health, the environment, violence, and legal issues.

SOFA, founded Klinik Fanm in 1997 as the first clinic in the country dedicated exclusively to the needs of women. Located in one of Port-au-Prince's poorest neighborhoods, Carrefour-Feuilles, it serves a community that was specifically targeted for paramilitary violence during the coup. This facility is supported by APROSIFA (Association for the Promotion of the Integral Health of the Family) whose founder Rosanne Auguste currently works training community health workers in the country. The clinic was originally established to provide medical care, counseling and human rights training to women who were subjected to rape and other forms of political repression during the coup.

Among its founders, we find Rosanne Auguste who describes thus the itinerary that led her to this place;

I grew up in my native village, Jeremie, where I attended primary and secondary schools. The philosophy of life I now hold has developed mostly from my family experiences. My father was very critical of Haitian society. He was a professor of Letters and Social Sciences. My mother was also very combative. She was a nurse and midwife. I inherited her dynamism, insight, and desire to work with deprived segments of the population. So, I inherited some of the values and personality traits of my parents that started me on my way towards this life of militancy.

I left Jeremie around 1982. I made a brief trip to North America but quickly returned, as I had never wanted to live in a foreign country. Upon returning to Haiti, I studied at the School of Nurses in Port-au-Prince; it was here that I began to assert myself as a true activist. That was during the period of the move towards democracy, after Duvalier had departed. This period brought into question the role and legitimacy of all the institutional structures. It was in school that I developed what I will call organizational sensibilities. This led to the creation of an association, of which I am the president, which then integrated into the National Federation of Haitian Students… which brought into question the role and the legitimacy of the institution of the school itself. ...

During the coup d'etat and after the nursing studies, I continued to fight within the Union of Nursing Personnel until 1992. As a nurse, I always preferred the holistic, naturalistic health approach. I always wanted to use methods which the community could interact with and understand as opposed to the formal, rigid hospital approach. This also has supported my activist work; it is also what led me to found the humanitarian clinic, the Klinik Sante Fanm, which is supported by APROSIFA. I continue to work, to fiercely question and analyze general social problems, especially the problem of health... " (Interview in Peace Brigades International newsletter, 10/1999)

Since its founding, thousands of women have used Klinik Fanm's services, which include gynecological exams, testing and treatment for sexually transmitted diseases, family planning, trauma counseling and health education workshops. In the Spring of 1998, the clinic was ransacked by a paramilitary unit of the police claiming to be looking for weapons. The clinic was out of operation for six months as a result of the attack, whose authors were left alone. A year later, the clinic is back in operation, with plans to establish a mobile ‘Klinik Fanm’ to serve directly women and children who live in rural Haiti who have virtually no access to health services of any kind. Klinik Fanm will also offer culturally appropriate, community-based health education and counseling program for rural Haitian women that will offer workshops in a communal space when the mobile health clinic visits their communities.

(PBI Newsletter 10/99; NetAid website (www.netaid.org)12/99; Human Rights Watch reports)


The question of ‘Indigenous Practices"

The question of ‘indigenous practices has two sides, although in much of the mainstream discourse, the focus on harmful practices like female genital cutting has obscured the other side: positive, well-established female health practices which have been under increasing attack in the twentieth century because of their control by local, often female practitioners and their reliance on ‘low-tech’ approaches.

In Australia as well as in Arctic North America, women have increasingly found support in their resistance to the reliance on birthing clinics far away from women’s homes, in environments that are considered, not always justifiably, safer for the women and the babies. They have demanded the ending of the practice of automatically flying women in the last stages of their pregnancies away to hospitals sometimes hundreds of miles from their homes, where they must experience what in many cases is a healthy natural birth in alien, overmedicalized environments. At times, the women have been made involuntary and uninformed guinea-pigs in medical experiments. But even without going to such extremes, the net effect of this widespread practice has generally been to disempower the patients, as well as undermining the transmission of what are often sound traditional practices.

In a similar vein, part of the movement for People’s Science in India has involved a conjunction with women’s empowerment in the reexamination and systematic updating of indigenous health practices.


Indigenous Health Practices Examined in Pre-Beijing Meetings in India

The Aikya center in Bangalore India held workshops as part of the preparation for the Beijing Conference. Activists from a dozen or so organizations came together to review, network and build on their experiences of Indigenous Health Practices, especially in terms of women’s empowerment and well-being. They agreed to share their experiences of promoting Indigenous Health Practices (IHP) through women healers and community groups. The aim was to evolve or use a gender framework for analyzing the experiences.

A number of features emerged

1. Health care facilities are often inadequate in the rural areas and slums, especially for women.

They found the common health problems and gynecological complaints were neglected for reasons of costs, and it was IHP, especially the use of tradiherbal medicine by local practitioners that could provide fast, cost effective primary health care for many common complaints

IHP thus has a key role to play in providing local, decentralized, and affordable primary health care

Local women and men healers in traditional Indian modalities were identified, provided further training on diagnosis, hygiene and laboratory technique through health camps, workshops and regular meetings reaching out to large numbers of practitioners.

Ayurvedic herbal gardens were established with the help of medical students and became the focus of work and exchange. Both male and female traditional healers have been trained in modern abpratpory work to support their practices, and they are increasingly helping in identifying and registering remedies.

(based on Imrana Qadeer Women and Health: A Third World Perspective and Dialogues on Health -- Women towards Beijing in Lokayan Bulletin 12:1/2, 1995

Some ‘traditional practices’ are harmful, severely undermine women’s health, and even threaten life itself. Under the influence of the fundamentalist forces and religiously-based regimes that have arisen throughout the world, women’s right to reproductive health has been limited, often totally denied. In some countries, women are forbidden to seek treatment from male physicians: any male medical professional who treated a woman would himself be placed in jeopardy. If at the same time, women are denied access to higher education and there are few women health professionals, this effectively prevents women from getting medical care at all.

One traditional practice that has been widely denounced is "female genital cutting" or FGC. The history of the practice and its rationales are complex and its eradication has been complicated in the past by the identification of opposition to the practice with foreign domination. Whatever its rationale may have been in the past (and there are indications that it played different roles at different times) it is often considered necessary as an assurance of maturity or chastity and therefore marriageability. Actually it causes lifelong pain and suffering much beyond the time of the initial operation and represents a severe violation of women’s human rights. Opponents of the practice have lobbied the United Nations and, more directly, have worked to educate communities about this practice. Much has been done at the national and international level to deter and eliminate this practice. But national laws and international standards cannot assure rights unless actual behaviors and customs change. The abolition of FGC, like that of footbinding in China early in the 20th century, can only be effectively achieved by the people and communities whose cultures have sanctioned the practice.

In the following sequence, we will be looking at different approaches to the same human rights issue of FGC.

Fighting FGC as Part of an Integrated Health Approach

Uganda’s Reproductive, Educative and Community Health Program , conducted in partnership with the UN Fund for Population took an educative and community building approach to women’s health and FGC, reached beyond repression or preventive measures against a range of harmful traditional practices. Two notable features of the project strategy stand out: the high level of community participation and partnership in the implementation of project activities and the interlinkages among key project components.

The overall aim was to increase awareness of the negative consequences of FGC by all stakeholders in the community and to reach a consensus on alternative but equally important culturally valid ways of performing rites of passage. Programs targeted strategic members of the community including: women; community/religious leaders and opinion leaders; policy makers; health providers, including traditional birth attendants (TBAs); men (husbands); adolescents; and the circumcisers themselves. Research activities focused on collecting data on the extent and type of the practice and to establish the socio cultural reasons behind the practice, essential for the design of culturally appropriate and effective projects. Healthcare providers are trained to recognize and treat complications (immediate and longer term) of FGMC and to provide counseling emotionally disturbed circumcised women and girls. Income-generation activities provide alternative sources of livelihood for the circumcisers who rely on FGM as a source of income. Other positive traditional practices are reinforced and expanded such as the celebration of motherhood, dancing, singing and giving of gifts. The synergistic effect of this culturally sensitive approach was expected to reduce considerably the rates of FGC.

(UNFPA project files. Program Advisory Note, Reproductive Health Effects of Gender-Based Violence: Policy and Program Implications. UNFPA United Nations Populations Fund. 1998 )


Community action for women’s human right to health ENDS FGC

In Senegal, the practice was approached by way of a long-term health and human rights education process. This process took place against the background of several decades of repeated attempts to eliminate the practice by criminalizing it. This approach resulted at best in driving it underground without affecting basic attitudes and core beliefs. Thing were turned around by the concerted action of a string of Bambara villages.

The Senegalese community of Malikunda Bambara is becoming known throughout the world as an exemplar of community action for the human rights of women. The following account shows how women of Malicounda demonstrated the empowering quality of human rights education and show a way in which women can take significant action for change in their own communities, action which can affect national policies as well as cultural practices.

The women of Malicounda Bambara have made up their minds. They will no longer practice Female Genital Cutting (FGC) on the young girls of the village! There will no longer be annual ceremonies to mark the moment when "girls" become "real women" following the ancient traditions of their ethnic group. No longer will needles and razor blades be used to cut the girls. No longer the flow of blood. No longer suffering on the wedding nigh, no complications at childbirth. No longer will young girls die needlessly from infection or hemorrhaging caused by the female circumcision rite!

But how did a group of women from an group that has known and practiced FGC for thousands of years have the courage to stand up and say "no more" to such a powerful and ingrained tradition? How did they convince the other members of their community, particularly the men and the older women who fight to preserve Bambara traditions? The women tell their story.

"We had been enrolled in classes in the Tostan/UNICEF/Government of Senegal Basic Education Program in national languages and we women of Malicounda Bambara had begun to change," explained Maimuna Traore, President of the Management Committee of the village class. "We started thinking and talking about things in class that we had never before discussed, things that had always been 'taboo', you might say. We worked on problem-solving and tried to look at some of the problems we women have in our village and we thought of different solutions for these problems. We also learned about germs and the spread of disease and that made us think a lot about some of our traditions that might be dangerous for our children." As Maimuna talked, she cut up a large bar of homemade soap produced by the women of the class. "Actually, the Tostan program gave us a certain amount of confidence that we never had before. Confidence that we could change things if we wanted to."

"That's true," said another participant, "the education sessions woke us up. We received information that we never had before and the new knowledge has given us a voice in our community. For the first time, everyone listens when we speak, because what we say is based on objective facts." Kerhtio Diarra spoke: "We studied Human Rights, particularly the right to health. We learned that this right implies each woman’s freedom to decide for herself what she does with her body. She also has the right to preserve her body as it is, without mutilation or changes. This was a revelation for us since it was in contradiction with one of our oldest traditions: the circumcision of all female children. In fact, in our traditions, it is unthinkable not to circumcise girls - why! she should be the laughing stock of the community and never find a husband! We were told that an uncircumcised woman was "dirty" and unfit to prepare and serve food to those who study the Koran! Yet, we have always been uneasy about the disadvantages linked to circumcision. Many of us suffered greatly during sexual relations with our husbands and during childbirth. Many got infections or hemorrhaged after the operation."

After learning about the negative health consequences of FGC, the women of the class went to the Imam of the village and for the first time asked his opinion on the subject. Serigne Amadou Toure told them that not only did the Koran not oblige them to practice the rite, but that he himself was against it. He explained that his own first daughter underwent the operation without his knowledge. When he found out, he told his wife never to let it happen again. His other daughters were not circumcised. This was indeed [not] recommended by the Muslim religion. They merely had assumed that all the Imam's daughters would be circumcised. "This information gave us new and powerful arguments for convincing our husbands and friends to end FGC and we immediately added this information to a play we had created against the practice," says another participant.

"You know, we're now aware that we have the right to a normal and dignified sexual life! Our daughters also. So we asked ourselves lots of questions," says another participant, "For example: Is FGC an act of violence against our own daughters?"

The women first decided, as a class, to stop FGC. "Then we discussed that decision with the traditional and religious leaders of the village, as indicated in the modules of our education program. (Then), we did a theater play on human rights that included messages on the dangers of FGC, and we went to all the neighborhoods in the village - Binabougou, Julacounda and Kahaydacounda. We invited our village midwife to these sessions, and she was also convincing, since she had seen many cases of suffering among women and children caused by this practice. After only several months, the women of Malicounda Bambara had agreed to stop the ceremonies for this year and, indeed, to forever stop a practice that is no longer justifiable in our community because of the health dangers it poses for our daughters."

An elder woman who had been listening attentively to the younger women talking suddenly spoke out: "We old women were the ones who insisted that all the girls of the community be circumcised! Even when the parents were against it, we'd go take the child and do it when they weren't around. But I'm in the class and I learned about human rights. Did you know that every man and woman have the right to marry and live their lives according to their own beliefs? When I found that out, I realized I could no longer impose my will on my children and grandchildren."

The village chief who was present during the whole discussion gave his opinion for the first time: "I'm not a member of the class, but I support the women's decision. Life is constantly evolving. We have even heard that in Mali, where we come from, that people are discussing and questioning FGC. But changes in traditions take a long time. It's hard to put an end to an ancestral practice which has lasted for thousands of years.

(Molly Melching: Breakthrough in Senegal: The Process That Ended Genital Cutting in 31 Villages )


PREPARING FOR ACTION

FGC is not universally practiced. Perhaps it is not practiced here. Are there other ways in which women’s right to health is violated in your community?

The women of Malicounda found their way to the solution of a very tricky health issue, through a mixture of education, discussion, community activities, and long-term planning.

Determine the main health issues for your group and your community. What is available to your community in the way of health education and short- or long-term planning?

Lay out the possible steps to a general health care plan for your community.

Start out with the health rights of women enumerated in the ICESCR and the BPFA.

Also include any other health needs you believe to be essential to the well-being of women in your community.

Review budget allocations and the resources your country and community have for economic and social purposes to see if your plan would be economically feasible. Adjust the plan to make it feasible.

Review and evaluate your plan with medical and health care workers to assure that it is appropriate to the health needs you have identified. Adjust your plan according to their advice. Enlist their support in working to implement the plan.

What strategy will be needed to convince the responsible authorities? Discuss and prepare to present a human rights argument for the implementation of such a plan.

 

FGC In the Context of Holistic Human Rights

The extremism of some of the practices associated with FGC makes it a very easy practice to attack from an outsider’s point of view. The difficulties encountered by its eradication indicate clearly that there are hidden dimensions in the question, as was suggested by an incident in Egypt, where a court had upheld the ban on genital cutting, giving rise to a surprising attack by Egyptian women activists, grappling with the paradox of ending what is certainly a human rights violation in a fashion that on the surface at least violates other human rights. FGC is not an isolated fact. In ending the human rights violation of FGC, the Court was perceived to have buckled down under pressure by foreign bodies, specifically threatened cuts to foreign aid.

Pressure by foreign bodies, it is argued, amount to neutralizing democratic institutions based on the separation of powers. Ultimately, the writer of the item below feared that unless the whole society is imbued with human rights in every aspect, the abolition of FGC might be an empty gesture.

As the writers also pointed out, the routine blatant neglect of poor women’s rights to adequate healthcare, adequate food, adequate housing etc are not similarly punished by foreign aid cuts!

For centuries girls have undergone genital cutting as the price of being female in Egypt. (Although it is often considered a Muslim practice, Coptic Christians also have practiced it in Egypt and Ethiopia.) (In December 1997), the claim of Islamic religious justification was definitively rejected by the Egyptian Supreme Administrative Court. The Court upheld a ban on female genital mutilation, stating that it is not an individual right under Shar'ia and that nothing in the Q'uran authorizes it. While the circumstances of the decision are local -- it upholds the authority of the Minister for Health to issue the ban against FGM -- the result was expected reverberate throughout the Islamic world.

The decision underscores the position that mutilating young girls cannot be called a religious duty. The Court's statement as to Shar'ia will support activists everywhere who have been fighting the allegation that FGM is ordained by Islamic law. Most importantly, the ruling will support women working locally against FGM in their own countries, such as in the Gambia, where the Gambia Committee on Traditional Practices succeeded recently in persuading the Government to lift a ban on public discussion of the issues.

In Egypt, much of the public discussion is attributable to the efforts of the FGM Task Force, established in 1994. According to its position paper issued in October 1997, the Task Force organized on the basis of "a strong belief of a woman's right to maintain the integrity of her own body and engage in her own evaluation of what should and what should not be done." While the Task Force is concerned that a legal ban may result in backlash, including deliberate flouting of the law, the Court's decision reinforces the Task Force's position that religion should not be used to justify "the interference of a human hand to mutilate parts of the human body."

The Task Force position paper is helpful particularly on the question of support from outside the country. While the Gambia Committee enlisted outside support, as have other Southern NGOs with respect to other issues, activism by NGOs outside the country is not always productive and should be undertaken carefully. In light of the debate and sensationalization of the FGM issue that has taken place in the Western press, the Task Force position is highly instructive -- not only as to FGM, but to other issues that concern women in both South and North.

We relate to FGM as a development issue. Organizations who wish to support our efforts in combating FGM should have a consistent approach to the multiple issues of development...It is important that the different allies formulate their support in a way that serves our side of the frontline, and does not impose new burdens or concerns upon us.

As a human rights issue,(... it is) inconsistent to be troubled by the practice of FGM and close an eye to health policies which deprive poor women -- the majority of women -- [of] their basic rights of access to the minimal requirements of primary health care. (...) he threat to cut aid to Egypt as a punishment of the Egyptian government because of FGM or to pressure it to take measures, actually means the starvation of the people, and not the government, of this country... Such forms of international 'support' for the battle against FGM actually serve to reinforce the practice and indeed, control over women in general, as people engage into an illusory struggle over identity.

Furthermore, it is unacceptable for Western supporters of the battle against FGM to appeal to Egyptian state bodies to intervene to overturn a judicial ruling, even when that ruling is in favor of FGM. The Egyptian people have struggled for many decades for the separation of the executive, legislative and judicial authorities; they have fought numerous [battles] to defend the independence of the judiciary. To appeal to the president of the republic to intervene to overturn a court ruling is in violation of the principles of democracy that generations in the country have been fighting for...

Consistency and accountability to our agenda, approach and the forms of support we accept are strategic elements in our existence and struggle. Solidarity organizations in the north should be able to read into the lessons of the FGM backlash in our country and similar reactions to similar situations in other Third World countries.

The struggle against FGM is a struggle for the liberation of women and men from the values system that governs them both. Working towards change of this value system is in fact working towards changing society as a whole. It is already a struggle over several fronts. It does not need additional ones.

(FGM in Court and in Culture: An Advocacy Lesson from Egyptian Women. International Women's Rights Action Watch. The Women's Watch. Volume 11. No. 2. December 1997. Hubert H. Humphrey Institute of Public Affairs, University of Minnesota.)

This question of the interconnection of all human rights is one that is bound to arise ever more frequently. The following items all describe initiatives where particular aspects of female health were systematically treated as part of the whole context of the women’s lives.


Gynecological Health and Sexually Transmitted Diseases

Cervical Cancer is a widespread health problem endangering the lives of women throughout the world. The problem is quite severe in Northern Argentina. In the province of Jujuy (Puna), it is estimated that there are 75 women with advanced cervical cancer out of a total of 30,000 that inhabit the region. In developed countries, this disease appears in 9 women of every 100,000. Cervical cancer has been known to develop as a result of sexually transmitted disease (STD). 20% of the Puna's women are infected with the human papilloma virus (HPV), the most common sexually transmitted disease that affects the cervix. In response to this serious problem, twelve women in the village of Abra Pampa, created the association, "Warmi Sayajsunqo", which in Quechua means "Persevering Women."

Early in 1995 the organization obtained its legal standing. There were already more than 60 girls and women working in the association under the leadership of Rosario Andrada de Quispe, a 38-year-old uneducated indigenous woman of the Andean plateau. The mother of 7 children, Ms. Andrada had previously organized village women in a knitting enterprise that supports 40 women.

At first, with the support of a gynecologist– after researching the disease, they started broadcasting information about cervical cancer and its possible consequences. They also let women know the association had a medical specialist, persuading them to be examined. Within a week, 150 women had signed up for a gynecological examination.

Subsequently, 22 women who had studied the female body and its diseases so they could serve as "health promoters" began visiting villages. Together with the Carlos Malbran Institute, a health research organization, they started keeping gynecological records of the women in the region.

The coordinator of the project, a recipient of the Women's World Summit Foundation award– points out that the aim is "first to help women from the Puna region improve their standard of living a little bit every day, to let them know that by using contraceptives they can avoid having children if they do not have the means to feed them; and also to give them the possibility of medical examinations..." She knows that by just mentioning family planning she will have more than one person bristle with anger, and she feels obliged to make it clear that their objective is not to have less children, but to prevent the death of more mothers. "Health promoters will tell rural women that there are methods not to have more children. They do so with respect, without forcing them to take contraceptives or have an IUD inserted. We aim at making them aware of the importance of undergoing a medical examination from time to time, and of the choice they have of not bearing children when they cannot raise them properly."

The project is seeking the support of the government to extend the activities of the association. They are establishing a gynecological and a dental office.

(Adapted from Susana Chiarotti (CLADEM)— unpublished report to PDHRE March 15, 1998)

 

Sanpatong Family Care Project

The Sanpatong Family Care Project is a community mobilization initiative in Thailand that provides services to about 600 persons living with HIV/AIDS. Its goal is to reinforce traditional values to ensure primary health-care at home for People Living with HIV/AIDS; to mobilize a community to provide care at home; to promote the self-reliance of the infected persons; to change any negative attitudes of family or community members; and to promote self-reliance of families and individuals infected or affected by HIV/AIDS.

Created in 1992 the Sanpatong Family Care Project, located some 25 km south of Chiang Mai City in Thailand, currently serves about 600 Persons living with HIV/AIDS.

To look after one another when a family member is sick has been a tradition in the Buddhist culture of Thailand. This project has helped reinforce these traditional values through training of and support to family members, community volunteers and village leaders. Services also include health care visits and the provision of basic necessities. Quality of service is safeguarded by the participation of departments of the formal health system.

Meditation and spiritual care is a well accepted and necessary part of the project's work. Meditation is taught by local Buddhist monks as a means of helping those hardest hit discover tranquility and mobilize enough mental strength to continue with serenity.

The project also helps bring together small groups of about 30 persons living near each other in sub-districts. These support groups enable persons living with HIV/AIDS to share experiences and concerns with each other. Project volunteers also provide moral support and training on practical matters of self-care and self-reliance for people who are HIV-positive but who have not yet developed AIDS.

The project's community mobilization activities encourage whole villages to accept and participate in the care of People living with HIV/AIDS and their families. Training sessions involve village leaders who in turn ensure care for relatives and neighbours.

Thai grandmothers have always had important roles in the care and upbringing of children, and in running the household. Improving their nursing skills and, at the same time providing support to them, is one of the newer activities of the project.

The project provides support to about 600 persons living with HIV/AIDS; 60% women and 40% men. About 60% are asymptomatic, 20% present some symptoms and 20% live with full-blown AIDS. 900 persons are trained annually on home-care, community mobilization and self-help skills. Thirty group sessions, each training 30 participants, have been held every year since 1994.

The project has allowed a large number of individuals to take part in or receive valuable services at a minimum cost. This community mobilizing project has successfully demonstrated that through adequate training, traditional values can be reinforced and adapted to meet the challenges posed by the AIDS epidemic. Individuals, families and communities can do a lot to care for people infected and affected by HIV/AIDS. Experience confirms that private companies and civil society associations are ready to provide support to appropriate community-based programmes.

(Joint United Nations Programme on HIV/AIDS (UNAIDS)



ASSESSING, ADAPTING AND ADOPTING ACTION

Other than prostitutes, who is at risk for AIDS, how and why? Do you empathize with the prostitutes in the story above? Can you see them as beneficiaries of human rights just like yourself?

Prepare a component of your women’s health education campaign to deal with stds. Develop a model policy to address the problems. Present the model to the health care agencies and ngos in your community, suggesting cooperative efforts to control stds.

Are women in your community regularly screened for cervical and breast health? How can your group help to establish such services?


Integrated Health Care in Bolivia— La Casa de la Mujer and Kumar Warmi

Many women suffer from poor health in Bolivia, where rates of fertility and maternal mortality are among the highest in Latin America. Bolivia's total fertility rate was 4.8 births per woman in 1994, with rural rates significantly higher (INE, 1994). According to the 1994 National Demographic and Health Survey, maternal mortality in Bolivia is 390 deaths per 100,000 live births, with ratios as high as 610/100,000 in the Altiplano area. A significant number of maternal deaths, an estimated 27 to 35 percent, were related to home- induced abortion, which, although illegal, is widely practiced in Bolivia, Adequate safe medical abortion services are not available .1 The root causes of women's poor reproductive health status are a near absence of health information, education and services, coupled with limited access to contraceptives.

To respond to Bolivian women's urgent needs for reproductive health care and to help affect changes in policies and practices that have excluded Bolivian women, especially poor indigenous women, from information and decision-making, La Casa de la Mujer and the Centro de Informacion y Desarrollo de la Mujer (CIDEM) developed women-centered health programs that employ integrated approaches to service delivery. Although each program is unique, La Casa and CIDEM share some common approaches in their efforts to improve women's health.

La Casa de la Mujer in Santa Cruz and Kumar Warmi (Health Woman) a clinic operated by the Centro de Informacion y Desarrollo de la Mujer (CIDEM) in El Alto represented two very similar approaches to maternal health as the focus point of an integrated approach, to all aspects of health but also to all human rights.

Both clinics started from the premise that reproductive health is an integral part of physical, mental, and social well-being, i.e., a fundamental human right for women. It implies the right to the information, power and resources necessary to make decisions about fertility, childbirth, child raising, gynecological health and sexuality. Integrated services and education supported multiple dimensions of participants' well-being.

Both clinics were principally designed and administered by and for women, but also made major efforts to include the men in many of their activities, out of the knowledge that

1. Men and women ‘s medical needs are connected, but also

2. Women’s health needs are more likely to be assured if their partners, who often would stay away unless specifically asked to participate, support the process.

Finally, both clinics made an absolute commitment to involve women themselves in the design and delivery of health care, and offered health care as part of a spread of services designed to improve their quality of life.

Both centers found that community issues needed to be dealt with as a necessary foundation to their work with women’s health,. Health was connected with collective survival and the structural transformation of society. Thus the clinics responded to health needs of poor urban and rural women through direct assistance and service for broader social needs including education, clean drinking water, nutrition, neighborhood struggles against hazardous dumps and other environmental pollution, preventive health, legal rights, citizenship, unemployment, illiteracy and inadequate child-care facilities.

The women's movement was an important impetus in the struggle to confront these broader social problems. There was an understanding that reproductive rights is more than just fertility regulation; it encompasses multiple dimensions of life, such as conjugal relationships, psychological condition, even the availability of legal services as part of the structural conditions that can enable or impede the fulfillment of individual human rights Over the years, the clinics’ personnel were actively working for passage of laws against domestic violence.

Novel and creative methods were developed to facilitate communication among professionals, outreach workers and grassroots program participants. This was made particularly urgent by the nature of their clientele, including local people of the lowlands and migrants from mountainous Andean regions, who suffer discrimination and exploitation on account of their ethnic identity. One doctor defined the basic principles that characterized their learning climate as

• Using simple language and conversational style

• Creating a relaxed atmosphere that promotes interpersonal relationships, and

• Continuously incorporating the lessons in every aspect of the participants’ daily lives. This was done through discussions, games, skits, home visits, and support groups....

Both centers stressed continued learning and personal growth among staff, outreach volunteers and other participants. Personal growth in this case was interpreted not so much as improved economic, professional or social status, as internal process generating autonomy, confidence, and responsibility.

While there was an emphasis on transforming the vertical relationships that traditionally characterize medical service, simply talking of empowerment of the women clients and even urging them to demand their rights was not considered sufficient. What was sought and for several years achieved in this holistic health process’ was continuous learning and dialogue -- within professional teams, within the clients’ groups and between all of them-- .

At La Casa de la Mujer, women are viewed simultaneously as individuals, as family members and as members of a larger society. Consequently, La Casa's philosophy is that women's health is affected -- often determined -- by relationships, by experiences, and by domestic, political and cultural environments. Health care is one element in an array of services necessary to improve women's quality of life. La Casa de la Mujer is action-oriented and works to empower women as individuals and to build solidarity among women from all classes of society. La Casa has worked extensively with women in reproductive health service and education, while Kumar Warmi developed a new approach to health care practices that incorporates a gender perspective. La Casa's unique characteristics include its offering of multiple and diverse programs to address the complex needs and experiences of women; its ability to build solidarity among women from diverse sectors of Santa Cruz society; and its emphasis on communication as a way of empowering women. The solidarity of La Casa participants and staff has contributed to an understanding of reproductive health and sexuality as something shared by all women, but experienced by each group of women, and even by each woman, in a unique way, depending on her cultural reality, her class and ethnic position, and her life experiences. Reproductive health services are offered in conjunction with other social services, such as legal services and psychological care, and reproductive health is viewed as one means of improving the lives of both women and men in Santa Cruz.

With a strong basis in gender theory, CIDEM's Kumar Warmi project worked to transform health care through educational processes. The approach emphasises continued education and growth, the respect for differences; an integrated approach to education and service delivery; and a focus on interpersonal relationships. The project's primary objective is to provide education and health care to women in ways that allow them to share with others the knowledge, responsibility and decision-making about their own reproductive health, and to participate in the design of health policies and projects.

It recognizes health as necessarily linked to education, human rights and personal empowerment; it transforms conventional interpersonal relationships, so that doctor and client play more equitable roles in the process of health care. Something more complex than merely providing a medical service when required. These institutions were able to experiment with new approaches and methods that might not be possible in larger health projects or major hospitals.

These experiences showed that it is necessary to establish alternative parameters of success to complement conventional indicators used to evaluate health programs. The first objective of Kumar Warmi, for example was "to enable women of El Alto to participate actively in the identification of their integrated health needs and in the search for solutions." Other objectives include: "to offer educational and prevention programs together with health care for women," and "to offer integrated health care to adolescents, working from a gender perspective."

Normally the efficiency of a reproductive health project is measured by: number of client visits, number of intrauterine devices inserted, number of pills distributed, number of Pap smears done, in comparison to funds spent. The sustainability of Kumar Warmi was frustrated by the prevalence of these indicators, and underscored the need to identify parameters of success, which reflect qualitative changes in the participants and in the target population.

for instance, by learning to determine the extent to which reproductive health knowledge and responsibility have been internalized by participants, and how participation has affected health and well-being in the long-term. In what ways have participants initiated or become involved in other health activities or projects after their Kumar Warmi experience? How many women who come for the pregnancy test then follow up with consistent prenatal care? What are the rates of consistency for scheduled checkups or return visits related to IUD insertion, pills and Pap smears? To what degree and how do participants share their knowledge and experience with others?

Workshop for all members of the organization, (staff and clients) explored the experiences and customs of grass-roots participants, which ultimately enriches and broadens the staff's knowledge, attitudes and practices. The institutional emphasis placed on learning from local women reinforces staff efforts to engage in a dialogue with program participants as part of their professional duties. Over time, most staff members came to comprehend principles of participation, equity and gender.

The development of new perspectives on the part of the staff parallels changes among participants. They were helped to internalize concepts such as women's rights, self-esteem, and women's participation in decision-making.

Continuous learning and dialogue -- within and among professional teams and participants -- are key to transforming the vertical relationships that traditionally characterize medical service in most parts of the world. It is not sufficient to "empower" women clients and urge them to demand their rights, given well-established hierarchical power structures. Neither is it sufficient to educate medical professionals about the concepts of equitable relationships, gender perspectives and humane treatment. It must be a joint effort in which both groups learn and change. Kumar Warmi also made it a policy to coordinate with other organizations working with women or with health , by providing workshops and training to mothers' clubs, neighborhood associations, women's groups etc.

Arguably, these two clinics had been able to launch precisely the kind of process with the Beijing Platform for Action was concerned. It is therefore a major irony of this example that, having started in the 1970’s and achieved quite remarkable results, the pressure of ‘structural adjustment’ economics and changes in donors’ priorities eventually forced a retrenchment into more standard medical care, obliging both clinics to curtail the most innovative aspects of their work in order to retain access to funding without which they could not operate at all.

(Summary from the very complete and detailed study by Paulsen Dr. Susan Case Studies of Two Women's Health Projects in Bolivia - FHI's Women's Studies Project, Boston, 1998)

Although the two clinics described above were exceptional in the range of services they provided and their commitment to work within a systemic framework of human rights, aspects of their approach to health can be found in many other places.

For example, family planning programs at "Beyond the Womb"– a program of the Women’s Health Care Foundation in Quezon City, Philippines– included services such as counseling on domestic violence and breast cancer screening, as well as political lobbying for health reforms that affect women, Other initiatives address the challenges of making service delivery more gender-aware by transforming health workers’ attitudes and practices. The Women’s Health Project in South Africa uses a process of in-service gender training to strengthen awareness amongst doctors and nurses. Others still seek to involve the otherwise excluded and address gender, power and communication in innovative ways. ActionHealth in Nigeria uses comic strips and role plays to explore adolescent sexual health needs. The Stepping Stones training programme, now widely used in Africa and Asia, takes a whole-community approach to reducing women’s vulnerability to HIV infection. In São Paulo, Brazil, Pro-Pater was established as a complement to women-related programs, to ensure the support of women’s husbands and lovers: originally established to promote vasectomy, it went on counseling for male reproductive and sexual health, sexual dysfunction and infertility, and domestic violence.

 

Philippines -- Advocating for Gender-sensitive Research

One frequent obstacle is a lack of adequate knowledge of women’s physical and health needs. Gender sensitive research is urgently needed as the basis of advocacy. The Women’s Health Research Project (became) notable for its innovative strategy of pursuing research through the participation of a consortium network of research and service organizations. The responsibility for managing this research network and ensuring project outputs rests with another strategic partner, the University of the Philippines Center for Women Studies Foundation. The project has three key components:

• Gender-sensitive research focusing on Filipino women perception of reproductive rights and fertility-regulating technologies and on understanding the health needs of women victims of abuses;

• The development of participatory women-centered research methodologies and strategies in women health and reproductive rights; and

• Utilization of research results and databases for the development of user-focused advocacy materials to be disseminated to policy makers, planners, media professionals, women advocates and health practitioners. The project is providing support to the Women’s Crisis Center to undertake research and training activities on the impact of violence against women on women’s health.

It is the first attempt by the Center to undertake a comprehensive study of the links between violence against women and common health problems. The research provides an opportunity to systematize the information the Center has gathered in the course of six years of providing services to Filipino women victims of male violence.

Another notable feature of the project is that research results are to be translated into effective tools for advocacy.

In the case of gender-based violence, it is envisaged that advocacy support will focus on three important areas for policy changes and legislative action: the formulation and/or amendment of laws on women rights and RH; passage of the proposed anti-rape bill and a comprehensive anti-domestic violence bill being formulated by SIBOL, a consortium of women NGOs; and adequate governmental responses to the needs of women victims of abuse through the provision of medical subsidy and other necessary services.

(UNFPA project files. Program Advisory Note, Reproductive Health Effects of Gender-Based Violence: Policy and Program Implications. UNFPA United Nations Populations Fund.)

War Destroys Women’s Health

Laws and policies demonstrate long-term political commitment: they also play an important role in removing the many barriers to women’s access to health care, such as financial costs and social obstacles, including seemingly obvious things like lack of transport.

As an example, laws and policies play an important role in making pre-natal maternal care an accepted and socially supported part of pregnancy and childbirth. If safe motherhood is to be realized, a review of national laws and policies is necessary, particularly to address the following: ensuring access to family planning information and services, encouraging support for adolescents and children, removing barriers to access, regulating practice, delegating authority and addressing unsafe abortion.

Legislation in support of safe motherhood must include rules and regulations that allow and enable health workers at the periphery of the health system to perform specific life-saving functions. It also must go hand in hand with the legal provision of the whole spectrum of human rights: reliable public transportation to get to doctors and hospitals, a network of local facilities providing routine ‘pre- and para-medical’ care: advice about nutrition, healthy life practices, etc.; fair labor laws that protect women workers from health endangering work-sites as well as from excessive working hours, education to overcome ignorance, protection from sexual predators on the way to work and in the workplace, etc.

No matter how much is achieved in this way, wars routinely undermines it, sometimes drastically so. The wars of the last decade have forced women’s human rights advocates, health care workers and humanitarian agencies to focus on the their effects in terms of the human right to health.

The recent war in Kosova is but one example of the multiple ways in which women’s right to health becomes a major war casualty. A pediatrician Vjosa Dobruna set up an emergency medical care facility for women and children in Tetova, near the Kosova-Macedonianborder. Before being expelled, she ran the Center for the Protection of Women and Children in Kosovo. As a refugee, she worked to open three other centers in areas with heavy concentrations of refugees, part and parcel of an effort to reconstruct Kosovar society. She also worked to provide reproductive health care for refugees. During the Kosovo war, it was at one point estimated that 10 percent of all Kosovo refugees were pregnant, breast-feeding or caring for very young infants.

Such care has been virtually ignored by relief agencies until the past few years. Prompted by the Rwandan crisis, women in nongovernmental organizations who work on reproductive health care in the developing world started a campaign to make this care available in camps. In recent years, however, the agencies running refugee-relief work have been under growing pressure, from the Vatican, and more recently from the United States government, not to provide such services as part of the humanitarian package.

In some cases, the problem has persisted for several decades, as is the case of the Palestinian refugees served by the Gaza Women’s Center. In this case, we see a mention of one health-related effect of long-term marginalization resulting from decades of ‘quasi-war’: violence against women , which is a predictalbe, and by now well-documented, side effect of refugee-status.

Palestine — the Women’s Centre for Health Care, Social Assistance, Legal Counseling and Community Education in Gaza

The Gaza Women’s Center is designed to provide multifaceted services to meet the critical RH care and social support needs of Palestinian refugee women in the Gaza strip.

In its situation analysis, violence against women had been identified as a serious social problem by local women’s organizations which receive numerous requests for assistance from women in the community. From the outset, the problem of gender-based violence, including domestic violence, rape, battery and sexual harassment both within and outside the family, was specifically identified as a key area for UNFPA program support.

To respond to the diverse needs of Palestinian women refugees, a Women’s Health Centre was established in the Bureij Refugee Camp with the aim of providing an integrated package of services. The Centre was set up as a one-stop service delivery point offering needed care in the following key areas: RH/FP support specifically focusing on pregnancy and postnatal monitoring; the screening and prevention of female cancers; the promotion of responsible sexual behavior among teenagers; legal and psychologically counseling to assist women experiencing domestic violence; social counseling to promote women decision-making roles and awareness of gender equality issues; and a program of gymnastics which has proved popular and which is a strategic entry point for promoting other project activities.

Overall, the project promotes a women-centered perspective and aims at raising women’s awareness about the importance of their health and preventive care and about their human right to health. A strong outreach component cuts across all project support activities. An average of 15 to 20 monthly workshops focus on topics related to the projects major components: health, psychology and legal and social issues. These outreach activities have been successful because of the community-based participatory approach adopted by the project. Training is another catalytic activity of the project, contributing to capacity-building among health professionals both within and outside of the project.

(UNFPA project files. Program Advisory Note, Reproductive Health Effects of Gender-Based Violence: Policy and Program Implications. UNFPA United Nations Populations Fund)


Militarization and women’s health -CSW’s recommendations

With international wars as well as civil wars flaring up in various parts of the globe, the problem of the effec of militarization on women’s health has become a concern of many organizations working for the human rights of women. The 1999 CSW session to assess progress on the implementation of the BPFA critical area of concern: Women and Health issued the following statement to delegates and other NGOs

[...]

Recommendation: A full and active commitment on the part of member states to the reduction and ultimate elimination of dependence on arms and the military for security and to the pursuit of nonviolent conflict resolution and defense is an essential condition of the achievement of women’s health and the well-being of society. Actions taken in the name of national security and vital national interests such as forward basing of troops, invasions to control segments of populations, border watch, enforcement of authoritarian governments, imposition and privileging of dominant religious beliefs cause excessive and avoidable harm to the physical and psychological security of women.

(...)

The well documented physical and psychological harm of sexual abuse and exploitation that is integral to armed conflict also extends to post conflict situations. Both are uncontrolled environments that increase women’s vulnerability to communicable and sexually transmitted diseases, particularly HIV/AIDS which spreads rapidly and exponentially, affecting especially refugee and displaced women. To prevent continued and increasing deaths among women from the secondary effects of warfare special emergency and humanitarian services need to provide primary health care supplies, including reproductive health care supplies, other essential medications and psychological and social services. Paramount among the health care needs of women in conflict and post conflict situations is some assurance that the cycle of military violence will not continue to destroy and disrupt human life and well being.

Remedial attention must also be given to the health effects of long term military presence and temporary or visiting forces on women in areas of peace time stationing or forces on alert. Such effects include the physical and psychological trauma of rape and other forms of sexual abuse, exploitation in entertainment, including prostitution, sexually transmitted diseases and the mental stress caused by constant military drills and activities in their communities.

Women’s reproductive health is seriously damaged by weapons’ testing fallout and other pollutants introduced into their environments through military activity, often causing cancers in women and severe birth defects in infants born in such cases. Other assaults on women reproductive health result from the forced pregnancies and abortion imposed by military forces or for military purposes.

Essential health care and the meeting of other basic needs fundamental to survival and well being are constantly delayed and systematically denied by the priority given to military over social spending. Such denials of basic and reproductive health care also result from the limitation of access and restrictions on mobility imposed in cases of forceful occupation and armed conflict.

The ever present threats posed by militarization cause serious damage to women’s mental health, such as overall stress, phobia, and the emotional distresses resulting from sexually transmitted diseases, cancer, deformed babies, rape, sexual harassment and exploitation.

Militarized security erodes the environment, prevents the meeting of basic needs, violates human rights, and puts women in constant physical danger in peace as well as war. The full range of women’s health and well being is undermined by militarism. Peace is a fundamental precondition of women’s health, and the state of women’s health and well being is a primary indicator of human security.

Drafted on behalf of: Working Group on Gender and Human Security/Ad hoc Committee on Military Violence Against Women/International Peace Research Association/World Council for Curriculum and Instruction/Women’s International League for Peace and Freedom/African Caucus/Asian Caucus March, 1999

Suggestions on the extension and distribution of this statement and the addition of other sponsors are welcome. Please contact the Ad hoc Committee on Military Violence Against Women at <bar19@columbia.edu>.



MAKING CONNECTIONS: MOVING TO ACTION

After reviewing what your group knows of present and recent armed conflicts, see if you can add to the list of ways in which war and militarism affects women health.

In what areas of the world are women suffering these assaults on health and well-being?

Are all of these health effects being addressed by the media and aid agencies?

How might your group make better known the multiple health detriments imposed by war and militarism on women ?

Research the comparative spending of your country and others on health care vs. military expenditures (See sources listed in For Further Information). Which is greater, and why?

Is lack of resources allocated for women’s health care seen as a consequence of military spending? Contact your government institutions charged with health care to raise this question.

"War is not healthy for children and other living things", was a slogan of the women’s anti-nuclear movement in the 1960’s. What might be suitable slogans to raise public awareness and provoke official action to understand the links between war and militarism and women health? What questions should be asked in the media and at political meetings?


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