25 years of international activism for women's health: gone with the wind?

What [is] wrong with [the Millennium Development Goals]? According to ... the UN Secretary General's office, the only substantive difference is that the reproductive health goal has been removed. Although discrete goals and indicators on maternal health and contraceptive prevalence are still included, there is nothing about reproductive health for all by the year 2015. Thus does 25 years of international work for women's health vanish into thin air, not with a bang but a whisper." (1)

Marge Berer, editor of Reproductive Health Matters

Making History

In September 2000, the United Nations General Assembly expressed its "satisfaction that, for the first time in history, so many heads of State and Government have gathered at a summit in New York, which reached a successful conclusion with the adoption of the Millennium Declaration," (2) a document that reaffirmed "the purposes and principles of the United Nations Charter, which have proved timeless and universal." (3)

The Declaration identifies several essential values for international relations in the 21st century, such as freedom, equality, solidarity, tolerance, respect for nature and shared responsibility through which the international community of women should obtain the full incorporation of their rights, needs and demands.

At this meeting, eight Millennium Development Goals were approved with 18 targets and 48 indicators to measure progress, which will be evaluated by a group of experts from the United Nations, the International Monetary Fund, the Organisation for Economic Co-operation and Development, and the World Bank

Some Concerns

The consequences of this Summit still cannot be measured fully, but the meeting itself occurred without provoking a ripple among civil society organizations, especially including the international women's movement. Civil society was not even invited to participate when crucial decisions were made: decisions that would have a decisive impact on women's lives--and indeed, the lives of all people.

It is not only feminists who are expressing concern about this failure to take our demands into consideration but the Special Rapporteur of the UN Commission on Human Rights, who stated in 2003 that the Millennium Development Goals had not been formulated from a human rights perspective and made several recommendations. Arguing that some of the Goals fail to adequately address reproductive health, the Special Rapporteur also demanded that greater attention be paid to the situation of poor women, minorities and indigenous populations. While the MDGs are intermediate objectives in the effort to guarantee the right to health, the criteria of human rights demand "the progressive achievement of rights, which is of decisive importance. Otherwise, these rights will be robbed of their content and remain empty rhetoric." (4)

There are two other crucial problems as well. On the one hand, given that the MDGs' are remote from the social, political and economic contexts in which they must be realized, (5) they transfer authority and legitimacy from the UN to the international financial institutions. The application of the MDGs uses poverty reduction strategies that require countries to fulfill macroeconomic indicators set by these bodies. On the other hand, the Millennium Countdown, to be implemented by the most highly indebted nations, is also based on these same indicators. Thus, even the best intentions of the UN are overridden in practice by the mandates of the World Bank and the International Monetary Fund.

Surrender or Pragmatism?

After a decade of international summits and conferences--the International Conference on Population and Development (ICPD, Cairo) and the Fourth World Conference on Women (Beijing), among others, in which the international community engaged in laborious processes of consensus and established extremely meaningful programs and platforms for action--and the five-year reviews (ICPD+5, Beijing+5, etc.), the fact that the detailed contents of these commitments--promises assumed by the States that took part in these conferences--are reduced to a paltry eight Goals represents a significant failure.

The atmosphere at the official Cairo and Beijing evaluation processes was almost festive. The UN presented summaries of the government reports that reflected a significant change from the period of stagnation in the early 1990s to a new scenario of progress, the result of actions by most countries to transform policies, plans and programs, although in most cases only the language was changed.

As a result, even though there were some differences in the extent of the progress made in each country, it seemed as if the course was set towards the inevitable achievement of the changes demanded by women.

Therefore, the reductionist spirit of the MDGs in 2000 surprised the international women's movement, as did the isolation and silence in which so many heads of State made such a transcendental decision, a process so very different from the observation and participation that women's groups had achieved in the Cairo and Beijing meetings. Even though the Millennium Declaration does not state outright that its objective is to replace or to divert attention from the commitment to fulfill the Cairo and Beijing agreements, neither does it recognize that implementation of the Programme of Action and the Platform for Action is essential to achieve the Millennium Development Goals and their respective targets.

Analyzing the MDGs

Goal 1: Eradicate extreme poverty and hunger.

Neither the targets of this Goal--halve, between 1990 and 2015, the proportion of people whose income is less than one dollar a day and halve, between 1990 and 2015, the proportion of people who suffer from hunger--nor its indicators, take into account the unequal distribution of wealth among countries, within countries, or between genders.

The so-called "vulnerability" of women, which is nothing less than the direct result of the traditional gender-based discrimination of patriarchal societies, means that women endure poverty and extreme poverty in greater numbers than men. All the internationally recognized indicators reveal that most of the households living in poverty or extreme poverty have female heads of household.

When analyzing gender inequalities, socio-economic aspects are of crucial importance since living conditions have a different impact on women and girls with regard to the perception of illness, health status, use of health services, payment for health care, and resources allocated for health and disability. (6)

Goal 2. Achieve universal primary education.

Although this Goal promises to ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling, specifically mentioning the genders, the indicators merely refer to children in general, both with regard to the percentage of children enrolled in primary school who reach grade six or the literacy rate among adolescents. Nonetheless, of the 150 million children between the ages of six and eleven who do not attend school, more than 90 million are girls. The different situations that affect girls' access to education and the obstacles that their families face must be clearly examined and addressed. Achieving gender equity in education will make a decisive contribution to the eradication of poverty.

Goal 3. Promote gender equality and women's empowerment.

This is the only MGD that explicitly acknowledges the inequalities that affect women. Its target proposes to eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education no later than 2015. However, this gender perspective has not been included in any of the other Goals or their respective targets.

The indicators that measure this Goal refer to inequalities in education, and they measure literacy rates disaggregated by sex, the proportion of women in paid jobs, and the proportion of women representatives in the legislature. Nonetheless, the will to promote women's equality and autonomy is reduced to education, "non-rural" employment and the presence of women in only one of the branches of government. Many other dimensions in which inequality is rampant are left untouched: women's lack of decision-making power in production, reproduction and sexuality; in public policies, the economy, commerce, land ownership, legislation, wealth distribution, armed conflict, forced displacement, and the many manifestations of cultural and religious oppression that are imposed upon women in their daily lives.

Addressing education alone will not resolve all the problems that women face, problems to which women with lower levels of education are especially vulnerable: gender-based violence, the feminization of poverty, the HIV/AIDS pandemic, maternal mortality related to complications of pregnancy, birth or abortion, and the limited representation of women in all branches of government, particularly at decision-making levels.

Goal 4. Reduce child mortality.

The target of this goal is to reduce by two-thirds, between 1990 and 2015, the under-five mortality rate. One of the indicators includes reducing infant mortality and measuring the percentage of children vaccinated against measles. Again, the specific situation of girls is not mentioned even though in different regions of the world girls endure multiple forms of discrimination even before their birth. This Goal also reduces the comprehensive health of children to the issue of mortality alone.

Goal 5. Improve maternal health.

The target of this goal--reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio--is possibly the most dramatic expression of the backlash evident in the MDGs. Women's comprehensive health is thus reduced to the traditional emphasis on care during pregnancy. Once again, governmental concern focuses on the "maternal mandate," which is women's destiny in a patriarchal society.

That's not to say that improving maternal health is not a positive step. However, the MDG indicators evaluate only the rate of maternal mortality and the percentage of births attended by specialized healthcare professionals. This is a case of too little, too late: maternal mortality is the result of a series of failures in a woman's life cycle.

Decades ago, the UN itself identified this relentless path towards maternal mortality, but today these imminently preventable factors that accumulate since birth are neglected in the MDGs. High-risk pregnancies, unwanted pregnancies, pregnancies resulting from rape, abortion in unsafe conditions (performed clandestinely of in substandard conditions due to poverty)--in other words, the primary causes of maternal mortality and morbidity are not addressed by the MDGs.

Measuring the consequences of unsafe abortion, one of the totally preventable causes of maternal mortality, is not included among the indicators for this Goal. The Goal also fails to address the issue of breast cancer or cancer of the reproductive organs (illnesses that are affecting women at increasingly early ages) or the multiple problems that face adolescents with early pregnancies. At the same time, the failure of this Goal to draw attention to the links between women's health and the numerous conditions that make them more vulnerable, including poverty, make it highly unlikely that any really improvement will be realized.

Goal 6. Combat HIV/AIDS, malaria and other diseases.

One of the targets for this Goal is to have halted by 2015 and begun to reverse the spread of HIV/AIDS, and one of the indicators for this target is the HIV rate among pregnant women aged 15 to 24 years of age. But the importance of guaranteeing access to sexual education for women and menor male responsibility in the realm of sexuality and reproduction are not mentioned. Knowing how many women are affected by the virus is not much use against a pandemic that has had an increasing impact among women in recent years. Greater understanding of the biological, social and cultural factors that have given course to the rapid feminization of the pandemic is complete biased by the removal of any mention of sexual rights or reproductive rights from the MDG discourse.

This target's other indicator, which looks at the percentage of condoms used within the rates of contraceptive use, muddies the water by bringing in the issue of reproduction: using condoms as a family planning method is not the same as using them to prevent disease. Again, women are at a disadvantage in the negotiating condom use with men.

In addition, Point 19 of the Millennium Declaration commits countries "to provide special assistance to children orphaned by HIV/AIDS." However, in the MDGs this promise is reduced to evaluating the ratio of school attendance of orphans to school attendance of non-orphans aged 10-14 years. How does this provide "special assistance?" (7)

Goal 7. Ensure environmental sustainability.

The appropriate relationship of people with the environment is one of the primary guarantees of sustainable development: women's welfare and wellbeing depends directly upon access to natural resources such as land, water, forests and agricultural production, among other factors. This relationship is directly influenced by the gender roles of women and men, and thus gender should be mentioned in the indicators of Goal 9's first target to integrate the principles of sustainable development into country policies and programs and reverse the loss of environmental resources. The second target--to halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation--also fails to recognize the contribution of women to agricultural labor, the production of foodstuffs and other goods, and their efforts to preserve the environment for future generations. The third target, to have achieved by 2020 a significant improvement in the fives of at least 100 million slum dwellers, should include among its indicators the right of women to own land and housing, as well as access to legal recourse to exercise this right.

Goal 8. Develop a global partnership for development.

The achievement of the numerous targets of this Goal will depend in part upon the political will and responsibility with which rich countries fulfill their commitments to development. A standard contribution of 0.7% of the GDP was set 30 years ago, but donations are less than half this amount. At the dawn of the new millennium, it was necessary to reaffirm this commitment since "the real problem is that many heads of state come to the United Nations, give their pretty speeches and make their promises, and then promptly forget them once they are back in their own countries." (9)

Most of the rich countries have reduced their contributions to the fight against poverty, and no specific responsibilities towards poor countries have been drawn up for industrialized nations, financial institutions, or multi-nationals with regard to the targets of this objective:

Address the special needs of the least developed countries; Address the special needs of landlocked developing countries and small island developing States; Deal comprehensively with the debt problems of developing countries through national and international measures in order to make debt sustainable in the long term; In cooperation with developing countries, develop and implement strategies for decent and productive work for youth; In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries; In cooperation with the private sector, make available the benefits of new technologies, especially information and communications technologies.

The breadth of these targets demands the existence of mechanisms for debate and consensus-building to realize the implementation of comprehensive international and national policies based on full respect for human rights, policies that mainstream gender perspective, establishing priorities and allocating resources to meet the different needs of women.

What's Wrong with the MDGs

In summary, the Millennium Development Goals are unsatisfactory for the following reasons:

* The MDGs are not based on the fundamental concepts of human rights, peacemaking efforts, reduction of military spending or the rejection of racism and xenophobia.

* They fail to acknowledge the existing frameworks of human rights and social justice.

* They do not address issues related to disabilities or the need to eradicate the stigmatization of people living with HIV/AIDS. They also fail to address the discrimination suffered by sexual minorities.

* The MDGs do not recognize the difficulties that ethnic groups and poorer sectors face when accessing any type of public service or benefit.

* They do not provide a global perspective on gender equality, equity or the empowerment of women.

* Women are perceived only in regard to their role as mothers and as caregivers.

* By not incorporating sexual and reproductive rights, the MDGs fail to take into account existing legal principles.

* The MDGs gloss over women's right to control their own bodies, including the right to contraceptive choice and the right to abortion.

* The MDGs do not take into account the needs of adolescents and youth or the different types of education and services that young people need.

* The MDGs make no mention of the various forms of gender-based violence, such as sexual violence or domestic violence.

* They also fail to mention the specific damages that women sustain in armed conflict, during territorial occupation, or situations of political, religious or military fundamentalism.

* They turn a blind eye to the different impact that poverty has on women's health, the results of the health sector reforms and the loss of solidarity-based social security systems.

* A neoliberal philosophy with an individualistic emphasis dominates the content of the MDGs. The urgent need for structural changes to eradicate poverty is missing.

* Out-of-pocket spending is viewed as insignificant when this is nothing less than the poor being forced to pay for privatized services.

* Health is viewed in opposition to sickness and death (i.e., treatment or prevention of HIV/AIDS, malaria, tuberculosis, measles), rather than as a state of well-being implied in comprehensive health.

* The MDGs do not explain how the expansion of the HIV/AIDS epidemic is to be halted without the recognition of sexual rights and reproductive rights.

* The MDGs confuse the means with the end, and the priorities are not clear.

* They promote the expansion of the World Bank and IMF influence over that of the UN.

* By subjugating the MDGs to the conditions of the international financial institutions, cuts in social spending that hinder access to healthcare services, education or community care are not questioned.

* The underlying causes of the problems are not examined; on the contrary, the focus remains in the realm of the technical.

Notes

(1.) Marge Berer, "Images, reproductive health and the collateral damage to women of fundamentalism and war," Reproductive Health Matters, vol. 9, no. 18, November 2001.

(2.) UN General Assembly, A/Res/55/162. Follow-up to the outcome of the Millennium Summit. December 18, 2000.

(3.) UN General Assembly, A/Res/55/2. United Nations Millennium Declaration. September 18, 2000.

(5.) Ana Guezmes, Reforma del sector salud y derechos sexuales y derechos reproductivos. Un enfoque integrado de derechos humanos, salud publica y genero. 2004.

(6.) Sarah Bradshaw, A Gender Critique of the MDGs (Nicaragua: CISAS, 2004) cited in Sarah Bradshaw, "The Millenium Development Geals and the Global Gender and Health Agenda," WGNRR Newsletter 82 (2004) no. 2.

(7.) Guezmes, Ibid.

(8.) Bradshaw, Ibid.

(9.) Eveline Herfkens, "Metas del Milenio a paso lento," online at http://www.choike.org/ nuevo/informes/2264.html.

RELATED ARTICLE: Coalition letter to the UN secretary-general.

On Sexual and Reproductive Health and Rights and the MDGs

Dear Mr. Secretary-General:

We would like to take this opportunity to thank you for your leadership in establishing the Millennium Project and for your recognition of the importance of reproductive health to the attainment of the Millennium Development Goals. We fully concur with your statement that:

   "The Millennium Development Goals,
   particularly the eradication of extreme
   poverty and hunger, cannot be
   achieved if questions of population
   and reproductive health are not
   squarely addressed. And that means
   stronger efforts to promote women's
   rights and greater investment in education
   and health, including reproductive
   health and family planning."

The Millennium Project has produced important recommendations for practical programs and policies in multiple sectors that will accelerate attainment of the MDGs in their overview report, Investing in Development: A Practical Plan to Achieve the Millennium Development Goals, and Task Force reports. We are pleased with the Millennium Project's efforts to strengthen integration of sexual and reproductive health and rights concerns into implementation of the MDGs. The Gender Equality, the Child and Maternal Mortality and the HIV/AIDS Task Forces in particular recognized sexual and reproductive health and rights as fundamental to progress towards the Goals. The overall recommendation to strengthen health systems and address girls' and women's health (including reproductive health) rings clearly in their analyses. The contribution of the Project in these areas and to encouraging priority for other neglected concerns (e.g., infrastructure, energy, multiple dimensions of women's empowerment) is an indication of its wise counsel.

We strongly support the Project's endorsement of universal access to sexual and reproductive health information and services, including family planning; protection of sexual and reproductive health and rights as critical pathways to achieving the MDGs; and the recognition that highest levels of unmet need for family planning and reproductive health services occur in the poorest countries among the poorest populations.

We are encouraged by the strong statements of reaffirmation, which emerged from the regional and other UN meetings held to mark the tenth anniversary of the International Conference on Population and Development. We also note the outcomes of the Countdown 2015 Global Roundtable, the NGO-led review of the ICPD supported by the European Union, as a demonstration of additional international support for sexual and reproductive health and rights. Taken together, these statements demonstrate the international community's continued commitment to the ICPD Programme of Action and its goals. Through these meetings, governments also affirmed their view that implementing the ICPD Programme of Action is essential to achieving the MDGs.

In light of the Millennium Project's recommendations and continued strong international support for expanding access to sexual and reproductive health services, including HIV/AIDS services, we trust that sexual and reproductive health and rights concerns will be clearly addressed in your report for the General Assembly High-Level Plenary.

To this end, we recommend that your report:

* Include specific language on the importance of sexual and reproductive health and rights to achievement of the Millennium Development Goals and the overarching goal of reducing poverty;

* Endorse as strongly as possible the findings and recommendations of the Millennium Project and its Task Forces, including those regarding refinements of targets and indicators for the various goals;

* Acknowledge the international community's continued support for the goals of the International Conference on Population and Development's Programme of Action, the Beijing Platform for Action, and the agreements of the other major UN international conferences of the 1990s as foundations for the Millennium Development Goals and the importance of their realization to achievement of the MDGs.

Similarly, we recommend that the ongoing technical review processes adopt specific recommendations of the Task Forces--in particular those of the Task Forces on Child Health and Maternal Health, on Education and Gender Equality, and on HIV/AIDS--including a specific target on universal access to reproductive health services under the Maternal Health Goal and several indicators relevant to sexual and reproductive health and rights within the indicator framework for various of the goals and targets.

We realize that the timeframe for finalization of the Secretary-General's report is very short, but we felt it was important to have the full benefit of the work of the Millennium Project--given its mandate--before communicating directly. Moreover, as the opportunities for civil society engagement in the Millennium Summit process are somewhat limited, we feel obliged to take advantage of every opportunity to share our concerns.

In conclusion, we note again our appreciation for your efforts to advance implementation of the MDGs and in particular the work of the Millennium Project. We look forward to working with the UN system, UN Member States, and other civil society actors on our common agenda for development over the next decade and beyond.

Yours sincerely,

Amy Coen, President, Population Action International (USA)

Frances Kissling, President, Catholics for a Free Choice (USA)

Jill Sheffield, President, Family Care International (USA)

Nirvana Gonzalez, General Coordinator, Latin American and Caribbean Women's Health Network, LACWHN

The author is an Argentine physician and the director of the Nicaragua's SI Mujer, an alternative health center for women. She is also a member of LACWHN's Board of Directors. This essay is based on her presentation at the roundtable entitled "Sexual Rights and Reproductive Rights in the Context of the Millennium Development Goals," held at the 5th World Social Forum, the First World Social Forum on Health and the Fourth International Forum in Defense of the Health of the People, "Health for all is possible and necessary," Porte Alegre, Brazil, January 2005.