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Millennium Development Goals Panel Discussion:
Improving Health and Nutrition
Task Force Coordinator Allan Rosenfield, Dean, Mailman
School of Public Health, Columbia University: Maternal Health:
Transcript
Lisa Anderson: All of my best laid plans
about how we were going to go in the order of the program
have once again been capsized. We are going to start our discussion
for the second panel with maternal health and child health.
Our presenters will be the task force coordinators: Allan
Rosenfield, who is dean of the Mailman School of Public Health,
and not on your program is Dr. Ronald Waldman, who is also
at the School of Public Health, professor of clinical, population,
family health, and director of the Program on Forced Migration
and Health. Gentlemen. Education and gender equality.
Allan Rosenfield: Thank you, Lisa, and I
apologize for changing the order a little bit, only in that
I have something I must be back up at the medical center.
I'm going to talk a little bit about the task force on maternal
health and child health. I'll focus for three or four minutes
on the maternal health side, and then Ron will say some words
about the child-health side.
One introductory comment. It's good that we have these three
task forces here, because one of the challenges for the MDG
process is the interface and interconnections between these
as well as some of the other task forces. We, one, don't want
to duplicate what we look at and think about, but more importantly
they really interdigitate in very important ways. One of the
challenges, as we finish our first round of task force preparations,
is how do we put some of this together between the task forces?
The methodology of the MDGs—selecting priorities,
setting targets, monitoring progress—is not a new
approach for the health-care field, but we haven't done it
in the past as well as we might. What's really new is being
increasingly seen as a critical plank, this being a critical
part of the development agenda.
Maternal health and child health, people with expertise in
these areas, are at the table as fully vested partners in
this overall MDG process. This is an important step, because
oftentimes people concerned about and interested in health
are not part of that process. Hopefully through many of the
things that are currently underway we will indeed be able
to help improve the health and well-being of populations.
There are three interlocking lenses within both our task force
and the others. One is equity, focused on those who are poor
and more vulnerable as a result of poverty, and on human rights,
with health as a fundamental human right, and part of the
social fabric. Then, particularly for these three task forces,
and others, the health-care systems as they exist are not
sufficient; disease-specific programming is not sufficient.
We need significant investment in human resources, in management,
in a whole range of issues to strengthen a very weak health-care
infrastructure in many resource-poor settings throughout the
world. These will be essential to the ability to meet the
MDGs about which we're so interested.
Within maternal health, when the goals were established and
the means of meeting those goals, the one measure of maternal
health that was chosen in the end by the UN system and process
was maternal mortality. That's not an irrational choice, because
maternal mortality is indeed related to maternal health, but
it became the only measure for the wrong reason. Another important
component was reproductive health more broadly. Because of
pressures from the U.S. government during the negotiations
within the UN, everything having to do with reproductive health
was removed because of sensitivities in our current administration
of anything that includes the word reproductive in it, that
might somehow, in some direction, in some way, lead to a discussion
of abortion.
The rationale for maternal mortality, however, is that there
are somewhere between 500 and 600 thousand women who die each
year from complications of pregnancy. That amounts to one
each minute of the day. For this particular health tragedy
we don't need new technologies, new interventions; we simply
need to make care available for people who have complications.
There are some 275,000 estimated deaths in sub-Saharan Africa,
well over two hundred in Asia, and in North America we have
under five hundred.
The lifetime risk for an individual woman in Africa is one
in sixteen, in Asia it's one in 110 people, and in North America
it's one in thirty-five hundred. This inequity is unconscionable
because there is no need for this inequity to exist. We aren't
looking for a new vaccine, we aren't looking for new immunization
program, we aren't looking for some new molecular innovation.
We simply need to make it possible for a woman who has a complication
to obtain services.
One additional comment: we are putting back in, and let them
take it out again, a series of reproductive health goals and
objectives. That will include looking in a variety of important
reproductive health issues. The goals that were listed in
the MDG document said for goal five, "To improve maternal
health was to reduce maternal mortality by three-quarters
between 1990 and 2015," and the only indicators they
included were maternal mortality ratios, almost impossible
to measure accurately, and the proportion of births attended
by skilled health personnel, which is not a measure of how
well you're doing in maternal mortality reduction. We will
be modifying those indicators to ones that we think are more
appropriate.
In terms of reproductive health, as one example, there's some
350 million women who do not have access to safe and affordable
contraception. Undesired fertility contributes directly to
the number of women who risk death in childbirth, both because
they may be high risk or it may be they don't wish this pregnancy,
and they'll be part of the sixty thousand to a hundred thousand
women who die from complications of an abortion in a place
where the abortion services are unsafe and usually illegal.
Addressing childbirth complications, we need to address emergency
obstetrical care and access to it. My colleague is telling
me my time is up, so my time is up, and I will simply summarize:
we believe we know what works in relationship to maternal
mortality. We believe that it is an intervention that is doable,
and we will work through this particular MDG task force to
make certain that that becomes the major goal, coupled with
reintroduction of the reproductive health agenda. Thank you,
and let me turn over to Ron to talk about child health.
^return to top of page
Task Force Member Ronald Waldman,
Professor, Mailman School of Public Health, Columbia University:
Child Health: Transcript
Ronald Waldman: Thank you very much, Allan.
I think that it's a good sign that I'm going to find myself
I'm sure repeating much of what has already been said. We're
only halfway through the program, but I think it's a positive
thing that we all seem to be on the same wavelength.
I wanted to start with all apologies to Dr. Lee by relating
my experiences in getting to New York City from Washington,
DC this morning. I woke up and there was a traffic jam on
the road, I had to get my kid to school late, and then the
plane left not on time but with a substantial delay. When
I got to LaGuardia there were no taxis, there was a traffic
jam on the Triborough Bridge, but I did make it to my class
on time, and planned to show them a video of how to measure
malnutrition in refugee crises, but the VCR didn't work. Dr.
Lee, science and technology's a wonderful thing, but I use
this as a little allegory of our times. In fact, we do have
many of the tools that we need to achieve these Millennium
Goals; where we have to get better is figuring out how to
make them work right in appropriate circumstances.
Child mortality has fallen from 15 million deaths of children
less than five in 1980, to about 10.8 million deaths today.
Those gains have been made in really remarkable circumstances:
in the face of ever-increasing birth rates, in the face of
increasing antibiotic resistance and resistance of the parasite
to antimalarial drugs, and even in the face of the spread
of the AIDS pandemic throughout the world. Still, we've managed
to improve steadily one percent a year. The agenda, though,
remains largely unfinished. One of the great dangers of success
is that people abandon the cause, feeling this is done let's
get on with the next thing. In fact it's not done at all.
We're starting to see the slope of the decline of childhood
mortality stabilize in many places, and we're seeing those
favorable trends absolutely reverse in others.
The reasons are simple. The reason is that we've taken out
a large part of the easy chunk that needed to be done. What
we've done to date, we always address the easiest things first;
we have initial successes, but when it comes to coming to
grips with those most important problems that remain, that's
where we need to redouble our efforts, where we need to increase
our will.
We could achieve the Millennium Development Goal by reducing
child mortality by two-thirds from the 1990 levels before
2015, but we could do it in ways that we don't want to do
it. We could leave the poor behind. We could work on the easily
accessible populations with means to provide those safe and
effective interventions that exist for their children, and
not work on educating those people who require it, not working
on providing the services to the rural areas where people
have difficulty accessing quality health services now, or
for one reason or another decide on their own not to access
those services.
Equity is a large part of our theme, and we feel that the
Millennium Development Goal should say not a reduction in
two-thirds of child mortality, but a reduction by two-thirds
in every single socioeconomic group in every country around
the world. I make that point clear because if we look at the
distribution of countries that are on track to achieving the
Millennium Development Goals for child health, we find not
one single country in sub-Saharan Africa on a path to achieve
those goals at their current rate of progress. Again, as has
been said before by Jeff and others, we need to redouble our
efforts in sub-Saharan Africa and to make this time a real
commitment to doing things in the field there that will bring
about the results that we want.
I could stand here and recite the causes of child mortality,
and I could do that by naming a very short list of diseases,
so I will. There are five conditions that account for 70 percent
of child mortality in the world: pneumonia, diarrhea, malaria,
and measles, compounded, as was mentioned earlier, by malnutrition.
Malnutrition is a factor in fully one-half of deaths from
those other causes; it may not be the proximate cause of death,
but it's an underlying cause of death, and it needs to be
dealt with. Not only the kind of malnutrition that results
in hunger, not the kind of malnutrition that comes from not
having enough food, although of course that's quite a major
factor, but what we've learned in recent years is that it's
not only the quantity of a diet, it's the quality of a diet
also. Vitamin A deficiency, zinc deficiency, and iron deficiency
and other micronutrient deficiencies, inadequate intake of
vitamins and minerals is turning out to be an extraordinarily
important risk factor, and we need to find a way not only
to get more food into people's mouths but to improve the quality
of their diets as well.
As we progress, a whole other segment of causes of diseases
comes into account, and those are diseases that occur in the
period immediately following birth. We haven't even teased
out well enough the distribution of those diseases, nor do
we know exactly what the conditions are. We can't put names
on those conditions as well as we can the conditions that
kill children between 1 year and 5 years of age. But having
dealt with the earlier part, we begin to have more research
needs that are required in order to better be able to define
the remaining core of the problem that will be more difficult
to address.
Beyond that, I'm always reluctant to address causes of death
by names of diseases, because it's far more important in some
ways to list the causes of death differently, not by over-medicalizing
the problem and leaving it to the world of doctors like myself
and others. The real causes of death are that mothers don't
recognize the potential lethality of their children's illnesses
early enough. The cause of disease is that mothers can't reach
health facilities on time. The cause of death is that there
are inadequate numbers of trained health professionals manning
too few health facilities in most of the developing world.
Combinations of factors, both at the household and community
level and especially within the health system itself, are
equally important, if not more important, than coming up with
safe and effective interventions. Indeed, safe and effective
medical interventions currently exist for all of those diseases
that I've mentioned, as the leading killers of children. What
we need to do really is to be able to put that science and
technology into working order and address remaining problems
in the health system. Thank you.
^return to top of page
Task Force Coordinator Josh Ruxin, Assistant Clinical Professor of Public Health, Center for Global Health and Economic Development, Mailman School of Public Health, Columbia University: Fighting Disease
Lisa Anderson: That was excellent. Thank
you very much, Dr. Rosenfield. You can go off to your next
thing. We're going to be hearing from Josh Ruxin, who is an
assistant clinical professor of public health here at Columbia,
and he'll be talking about HIV / AIDS, malaria, other major
diseases, and access to medicine.
Josh Ruxin: And people wonder why I'm so
nervous right now. It's not because my colleagues covered
so many of the areas that I plan to cover, and then I rewrote
everything that I was going to say, and I can't actually read
my handwriting, but rather it was because I've seen Dean Anderson
and how she conducts her classes and holds people to their
time, and she has a series of different time reminders there.
It starts off nicely with "Time," and you can't
imagine what it becomes if you go over that.
A couple of weeks ago I was in Rwanda, and had a meeting one
morning with the head of the national AIDS program, and she
came in looking very upset, and she told me that it was because
she'd had a problem with her maid. I thought this seems like
it's some sort of bad joke about how hard it is to get good
help. She said, "No, that's actually not what happened.
My maid came in yesterday and she was very upset because her
granddaughter, Sophie, who's two years old, was just getting
sicker and sicker, and eventually was brought into the city
and was diagnosed HIV positive."
Of course, at that very moment her mother was also diagnosed
HIV positive, as was her father, who's a Kenyan, who was responsible
for this mess. The problem for Sophie, though, was that she
didn't have access to a good health center where she would've
received the prenatal care that would've prevented this in
the first place; her mother didn't have access to it either.
About a quarter of the health clinics there don't even have
running water, and yet they're called health clinics and health
centers.
So the mess that the head of the National Aids Council finds
herself in is that it's not just difficult to address issues
of HIV / AIDS or difficult to address tuberculosis or malaria,
or the issue of access to essential medicines, but rather
that the entire health system has eroded to such a state that
kids like Sophie and her parents and all of their friends
are not getting the health care that they need.
As you can imagine, we've got a big task force. We were originally
supposed to be one task force, but given everything that we've
taken on we've actually subdivided into four. There are about
seventy colleagues who've got expertise in these four major
areas, and one of the things that we're finding and facing
is that we've got a lot more in common than we would've anticipated.
We're not just going to take another vertical approach to
addressing these diseases, because the fact is that there's
one thing that all these diseases share, and let me just give
a quick list here. There are 45 million (roughly) people who
are HIV positive today, 25 million who have already died.
There's about half a billion episodes every year of malaria,
there's about two million deaths caused by tuberculosis, and
most people in developing countries don't have access to the
drugs that they need.
What do all of these problems share? All of this is treatable
and preventable, if you have the management and the health
systems needed to deliver it. So that's our primary challenge
on our task force, to figure out what are those bottlenecks,
and how can our task force identify some of the critical issues,
many of which members of the audience have already brought
up—issues like political leadership, issues like
empowering women? What can we actually do as a task force
in order to target it? We're working in a couple of areas.
On tuberculosis we are adapting successes from Vietnam and
Peru, and figuring out how to scale those up and integrate
them into a primary health-care system.
In malaria, we're trying to figure out how to have a more
comprehensive and integrated approach, which provides access
to essential medicines and to insecticide-treated bed nets,
as well as other solutions that currently exist but are not
being scaled up fast enough.
Under access to essential medicines we're looking at issues
of differential pricing, and in AIDS we're looking at some
of the more controversial issues, things like UN policies
which perhaps are actually drug policies in eastern Europe,
which are encouraging transmission of HIV / AIDS. What's different
about this task force and this project is that we actually
are situated outside of the UN. The secretary-general wanted
an outsider's opinion on what the United Nations can do to
address this. That's why we have lots of experts who are not
directly working with UN agencies, because we are to give
them an honest assessment of areas in which they can make
improvements.
Right now the papers that we're actually working on are being
presented in Kisumu, Kenya, by members of our task force,
to start to get feedback on the areas that we're deciding
to concentrate on, because we don't think that it's enough,
it certainly is not enough, to simply sit around a round table
here in New York or in Geneva or in Rome or elsewhere and
discuss these issues. We want to have people in these countries
taking control of what this strategy looks like, and they're
doing it at an astounding rate.
Because of the leadership that these countries are showing,
for example, our HIV / AIDS task force is meeting next month
in Rwanda. It's going to be opened up by President Kagame,
who's very excited to draw attention to the challenges, for
example, that they face there, as well as the enormous opportunities.
Our challenge is to figure out how to translate this into
action. I'll look forward to hearing your comments afterwards.
I think that overall our goal is to figure out how is it that
by the 2015, if not beforehand, we can find a way to start
delivering these very basic health services to the Sophies
of the world, to their mothers, to their friends, and to our
colleagues in the developing world. Thank you very much.
^return to top of page
Geeta Rao Gupta: Educating Women
Lisa Anderson: And now, Professor Cohen,
we're going to get to primary education and gender equality.
The task force coordinator is Geeta Rao Gupta, who is president
of the International Center for Research on Women.
Geeta Rao Gupta: Thank you, and good afternoon.
I know I'm going to disappoint at least one person in the
audience, and maybe more, because I am one of three coordinators
of the task force on education and gender equality; my other
two coordinators are Nancy Birdsall from the Center for Global
Development, and Amina Ibrahim, who runs the Education for
All Campaign in Nigeria, and both of them are not here today.
I'm the one who takes care of the gender equality piece, they
take care of the educational piece, so even though I do represent
that task force I will be focusing my remarks on gender equality.
But the good news is, in that I will be referring to girls'
education, so hopefully that will help some.
The goal of the task force, much like the other task forces,
is really to review the progress that countries have made
to date towards the goals that have been set in the Millennium
Development Goals, and then to make some practical recommendations
to hasten progress. Like the other task forces, our task force
consists of about thirty members who are from the UN, from
NGOs, from the academy, from the whole range of international
financial organizations. All of us have in common the fact
that we're optimists, as somebody from the audience said,
but we are pragmatic optimists, because as Josh just said
we have the strong belief that for all of the problems that
we have been asked to provide recommendations for we actually
have solutions. The problem is not that these are problems
without solutions; the issue lies in how are we going to get
those solutions implemented? That's the challenge.
As you probably all know, the disadvantages and discrimination
experienced by women are our legacy from the past century.
The goal of our task force is to ensure that this doesn't
continue to be our future.
You should know that there have been significant improvements
made in the last three decades in women's health and education
in particular, but despite that women and girls still lag
far behind men and boys in education, particularly in secondary
education, in health, you heard the statistics on maternal
mortality. On HIV / AIDS, women are now 58 percent of all
those who are living with HIV / AIDS around the world. Is
that around the world or in sub-Saharan Africa? In sub-Saharan
Africa. And 50 percent around the world. They are the ones
who are most vulnerable in situations of poverty, and they
often constitute the most marginalized segments of the population,
which means that they have the least access to key productive
resources.
The MDG offers an opportunity to rectify some of these past
inequities, and do what I think of as attending to the unfinished
business of development by fulfilling the many, many promises
that have been made through the UN conferences of the mid-'90s
to women around the world, and to communities around the world
to reduce poverty, to end hunger, to improve health, and to
eliminate illiteracy.
Gender inequality actually is a crosscutting issue, as you
can imagine, because it affects all of these problems and
is affected by them. It is exacerbated by each of these issues,
and it fuels many of these ubiquitous development challenges
that we are faced with. We know through data from the past
two and a half decades that gender equality and the empowerment
of women can in fact secure the future of women themselves,
but more importantly also ensure the future welfare of households,
communities, and national economies.
There's two things I like to say to audiences. Investing in
women is a good thing to do because it's the just thing to
do, it's the fair thing to do; that women should suffer disadvantage
and discrimination is just plainly put not right. It's also
the smart thing to do, because we know that investing in women
gives you a high return. The three most common examples provided
for that are in girls' education—we know that investing
in girls' education is the single best development investment
you can make. The returns on that in terms of child health,
in terms of reduced birth rates, in terms of improved maternal
health, in terms of improved nutrition, improved incomes—all
of those are related to girls' education.
We know that investments in women farmers, as somebody in
the audience pointed out, has huge returns for improving the
nutritional status of households, if those women farmers are
given the right inputs, the right technological inputs, the
right information on nutrition, and the resources to be able
to use that information and put it to practice.
Third, we have data from many, many studies from the '80s
that show very clearly that income in the hands of women in
poor households has welfare benefits for children and households
much more than income in the hands of men in poor households.
It's important to keep those three things in mind, because
the way our world is constructed today, it is the economic
efficiency argument that somehow carries more weight than
the human rights argument or the fairness argument or the
justice argument. Even though there is both an equity argument
and an efficiency argument to make in terms of creating a
case for investing in women, we often use the economic one,
the efficiency one, because that's very powerful and there's
lots of evidence to make that case.
To guide the work of the task force, what we have done is
we've adopted a framework of gender equality that speaks of
gender equality as having three domains. The first is capabilities,
which includes education, health and nutrition, it's the basic
human abilities that you need. The second is access to resources
and opportunities—to use those basic abilities by
being able to then use them to access economic assets, such
as land and property, and resources, such as income and employment.
The third domain is one that we call agency, which refers
to the ability to make choices and decisions that can affect
life outcomes. It can only result when there's an equalizing
of power in society between women and men, and some of that
equality and power arises from equal access to productive
resources.
All three domains, as you can imagine, are interrelated, but
they're not necessarily dependent one on the other, so you
can in fact have very poor women gaining agency by organizing
and mobilizing themselves. But interestingly, once they do,
what they ask for is those basic capabilities. So they're
sort of related, but they can function independent of each
other. We kept that in mind in trying to set the goals for
this task force and come up with the recommendations. Much
of what we have come up with has actually been said many,
many times before, and has been documented in all of the sort
of platforms for action that emerge from the Human Rights
Conference in Vienna, from the International Conference for
Population and Development in Cairo, from the WSSD in Copenhagen,
and from the World Conference on Women in Beijing.
All of that is reflected in this process that then resulted
in this goal. It is a peculiar goal, though, and I should
just mention this, because the goal says promote gender equality
and empower women, but the target only refers to primary and
secondary education. It is eliminating gender disparity in
primary and secondary education by year 2005, and in all levels
by 2015. While the focus on education is fully justified,
because it does yield high returns, we do believe that it
is not sufficient, because it leaves out the other two domains
of equality. So we have suggested for countries who are willing
to do so that they should be monitoring themselves in achieving
two other targets that we are suggesting, the first of which
is to eliminate gender inequality in access to economic assets
and employment by the year 2015, and to achieve a 30 percent
share for women in national parliaments by 2015.
We have also suggested that, for those who are willing, because
this is the UN system, and sometimes they're not, to add to
the indicators. So far there are four indicators for the goal
that have been approved through the Millennium process. Two
of them refer to education, one is on the share of women in
wage employment in the nonagricultural sector, and the last
one is the proportion of seats held by women in national parliaments.
We have just said that where possible please add for the education
goal, because the education indicator is only on enrollment.
We are suggesting, and the education cochairs are suggesting
this overall, that we use completion rates, not just enrollment
rates. It's one thing to get kids into school; it's quite
another thing to be sure that they finish six years of primary
education and can read and write.
The second is to try and gather where possible region-specific
indicators for gender gaps in earnings, in paid and self-employment,
and sex-disaggregated unemployment rates, and where possible
some description of the occupational segregation that exists
in different societies.
Finally, an indicator, a negative indicator, for agency, in
addition to the one about representation at parliaments, is
the prevalence of domestic violence in the past year in women's
lives in any given country, because domestic violence acts
as a huge barrier to women participating in decision making
at any level.
From the analysis we have done so far, we know that very few
countries will in fact, if they go at the pace they're going,
achieve gender parity by the year 2005 or 2015 in the education
indicators, and the female share of nonagricultural wage employment
in 96 of only 105 countries for which even the data are available
is less than 50 percent, so women are less than 50 percent
of nonagricultural wage employment. In only 11 countries do
women have 30 percent of parliament seats; in the majority
they have less than 10 percent.
To make up for lost time and to accelerate the pace of progress,
here's what we suggest that the world should do. The first
is to ensure the availability of quality data on women's lives.
I find it absolutely unconscionable that here in the twenty-first
century we still can not tell you the story of women's lives
in all countries around the world, and compare that story
across countries. The most notable gaps are on women's economic
activity and decision-making ability. We don't have the cross-country
data, for example, to talk about women's earnings in different
industries and occupations.
We don't know women's participation and the extent and nature
of it in the informal economy. We don't know prevalence rates
for domestic violence. We don't know women's share of seats
in municipal and local level legislative bodies. We are pushing
hard for good data. As somebody—a very, very sexist
remark, so don't ever quote me—but somebody once
said to me jokingly, "Ha, so I guess good figures—women's
figures matter." They do. Figures matter in policy. You
can not recommend policy, and you can not monitor policy without
data. You need data to do that. So we are pushing for the
UN Statistical Institute to ensure that they can rectify those
gaps, and we are asking ECLAC to take the lead, which is a
UN agency in Latin America, in standardizing existing sets
on women's lives across the world.
Second, we're asking for greater financial and technical resources
for national level women's machineries, which is the women's
departments; almost every government now has either a women's
welfare and sports ministry, they have all kinds of peculiar
combinations, but they do exist. There are departments for
women's affairs, yet they are the least resourced of any ministry
or department in any government, and they have the least number
of technical staff available, and that's a big problem. The
same is true for agencies within the UN system, so that UNIFEM,
for example, is the least resourced. I was stunned to hear
that the U.S. contributes all of one million dollars to UNIFEM
a year. That is astonishing compared to the levels of giving
to the other UN agencies, and yet UNIFEM is the one responsible
for gender equality within the UN system. The gender units
in the World Bank, in WHO, all of them are constrained by
limited budgets and by the lack of technical skills in their
staff.
On the substantive side we are suggesting the following: that
there are existing policy frameworks and mechanisms that just
need to be strengthened. We don't need a whole lot of new
ones. The Education for All Campaign needs new resources,
but more importantly needs coordination at the national level.
They're getting overwhelmed with multiple international mechanisms.
There are the PRSPs and a hundred other things that governments
are trying to handle. How do we make that coordination happen?
Get them to measure completion rates, not just enrollment.
For reducing poverty, we want to ensure that the Decent Work
Initiative of the ILO—and I can tell you more about
that in the discussion, since my time is up—is something
that should get higher visibility and be better resourced.
In terms of assets for those in poverty, we want property
and inheritance rights to not just be guaranteed in the law
for women all over the world, but actually enforced. You'd
be stunned to know that there are many, many countries where
women still don't have that.
Finally, with regard to violence against women, we have asked
the secretary-general's office, and this will become a more
official process soon, to spearhead a new campaign for zero
tolerance of violence against women, because we would like
to bring to his attention that this is of epidemic proportions,
much like HIV / AIDS. In fact, because of the epidemic in
southern Africa now, it is of epidemic proportions, violence
against women, particularly sexual violence. We need the data
to be able to show how the legislation that exists in most
countries can in fact be implemented, and what is the budget
that that requires, and that's some of the analysis that we
are undertaking.
I'll stop there and just say I agree with the person who said
what is missing in all of these goals is political will, and
that particular ingredient for the gender equality goal is
the most needed. We need leadership and political will. In
this country, for the students in the audience, I just want
to say to you to make that political will happen. Keep your
eyes and ears open, because there is a battle that's going
on currently—a battle between ideology and between
science. For those of you who have had the privilege of being
educated, you should be aware at all times and be in the forefront
providing the evidence that does exist to show that an inordinate
sort of dependency on ideology costs lives. It is not just
misguided morality that we can excuse, it costs lives, and
that's the case that we have to make more strongly. Thank
you very much.
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Questions and Answers: Transcript
Lisa Anderson: Thank you very much. We have
about ten or fifteen minutes for comments and questions from
the audience. Once again, please use the microphones.
Nisha Shitane: Nisha Shitane, World Bank.
Many of the panelists have touched on the cross-cutting, mutually
reinforcing nature of the MDGs, and I just wondered whether—and
you can improve education outcomes without addressing water
and sanitation, environment, and the other indicators. I just
wondered whether the ten task forces were planning to undertake
an analysis, merging the findings to identify whether this
multi-sector approach is the most effective way forward, and
where this analysis stands.
Geeta Rao Gupta: I didn't have the time to
mention this, but each of us actually was given the task of
identifying the task forces that we thought had the most to
do with our own task force, and then find ways to influence
those task forces. As you can imagine, the education and gender
equality task force has a whole bunch of them that we seek
to influence. We had to pick, because you can't do it all
to actively work with, so we picked hunger/poverty, which
is actually one goal, HIV / AIDS and other infectious diseases,
maternal and child health—though we are convinced that
that's being taken care of—water and sanitation, and
the task force that's dealing with slums. Those are the ones
that we are actually going to be attending each other's task
force meetings and trying to do some joint analysis so that
the gender issues in each of those issues will be more prominent.
Swati Rout: Hi, Swati Rout. It's actually
for Geeta as well as the HIV / AIDS—
Josh Ruxin: Josh.
Swati Rout: Josh. Great. Do you think this
woman's empowerment goal should be called as men's empowerment?Geeta Rao Gupta: I don't quite understand
where you're coming from, but I will—I will try to answer
that. If you mean by that that women can not be empowered
without support from men, is that what you mean? No.
Swati Rout: [Inaudible]
Geeta Rao Gupta: I see what you're saying.
Swati Rout: [Inaudible]
Geeta Rao Gupta: I think that this is really
a use of terms, and it's a very important point you bring
up because we struggle with this in the women in development
field a lot, and that's how do you raise the vulnerabilities
and disadvantages that women face and yet not portray them
as victims? It's because women in the developing world in
the poorest of households are not victims. They take what
little they have and they make the most out of it. Take a
lemon and make lemonade out of it—that's women for you
in poor households.
They do the most they can with what little they have. While
that is true, the point of the matter is they're doing that
at great cost to themselves, and with huge hurdles and constraints
in their way that have been put there because of the way in
which market forces, societal institutions, and the attitudes
of politicians have been for centuries presumed to be—presumed
that development is gender neutral, there is no difference
in women's and men's lives, or in their roles, or in their
access to resources. It is to remove those hurdles and those
constraints and make it easier for them to attain the power
that they could attain, that's what this is about.
I often say when I'm talking in the context of HIV / AIDS
that it's not that men in the epidemic have no power, they
have—there's an unequal balance of power, so we always
say, well, if they have the power, somebody asked me once,
how come they're not using it to do the right thing? The point
is that both men and women suffer the consequences of gendered
systems in society. There is pressure on men just as much
as there is on women to play particular roles, and to be a
particular way. So in the epidemic, for example, they are
forced in some way by society, because there are very strong
negative sanctions against them if they don't follow these
rules, to be sexually assertive, to know it all, even though
they're never given any information—to be brave and
experimental, to never ask or seek information. That has consequences
for the epidemic. So it is about gender, it's how roles are
characterized by society and the sanctions associated with
that, that has costs for both women and men, and therefore
for all of society.
Rachel Paneth Pollack: Hi, my name is Rachel
Paneth Pollack, I'm a student at the Mailman School of Public
Health. My question is for Josh Ruxin, I think primarily.
You alluded to differential pricing when you spoke for essential
medicines for very poor populations. I've heard arguments
for both that they should be entirely free and that there
should be partial subsidies. I don't know if you can get into
that more, but I'm wondering what you think about that.
Josh Ruxin: Unfortunately, that's not my
direct area of expertise, and we don't have the representative
who's based in Kenya right now from that task force. So I'd
rather not wander into an area where I don't have a lot of
knowledge. Thanks.
John Chuna Kasamakula: I'm John Chuna Kasamakula,
a public health doctor from Uganda. I just want to say, one
of the comments I hear often is about civil society, community,
community health, particularly for all these goals that we
have. But I very rarely hear what the communities themselves
have to say about it. We hear a lot of experts, they say this
is what we're going to do for them, what we think should happen
for them. How are we going to ensure that these goals are
actually going to be what the communities actually need or
want? How do we ensure that they have a voice, or is this
just going to go the same way as so many UN initiatives?
Josh Ruxin: I can. Okay.
Allan Rosenfield: Is this one of your areas
of expertise?
Josh Ruxin: As far as how this particular
project is going to get connected to communities, I don't
have a good answer for that. But as far as community voices
being heard in the creation of and management of their health-care
systems, I think that there's a major trend going on throughout
the world, whether you look at China or India or Ethiopia
or Rwanda or your country today, whereby there has been a
devolution of power to the communities to make the decisions
about what their health priorities are. This is actually one
of the issues that our task force is going to take a look
at—how it is that ten, twenty years ago many of these
decisions were just made by a federal ministry of health and
now they're devolving those decisions down to the community
level. It's going to be interesting to see what types of choices
are made, and I think that our project will help to inform
them, at least as far as what some of the major challenges
are going to be.
Allan Rosenfield: Just let me add my minutes
where I think it's an extraordinarily important question and
a fascinating one, because we can't separate communities from
the rest of government, or from international experts. I think
there are some things that the Millennium Project can prescribe
for the international community, and for the UN agencies;
there are certain strategies and certain approaches that are,
I think, reasonable to be able to suggest strongly be adopted.
But it's impossible to dictate to communities what they ought
to do, or to prescribe for them. As soon as any outsider prescribes
for a community what's best for that community, even if it's
right, there's going to automatically be a knee-jerk reaction
opposing it, and appropriately so.
There needs to be a lot of compromise done, as Josh says,
a lot of education. One of the major health sector reforms
in the past decade took place in Zambia. Zambia decentralized
entirely its Ministry of Health, including the budgeting authority,
down to the district and community level. They found that
when they did that, although they were empowered with the
ability to spend their budget any way they saw fit, a lot
of the programs that were being run in those districts were
not necessarily what one would consider to be the right ones.
Only one-quarter of those districts continued childhood vaccination
programs, for example, which are very, very high on the international
agenda. I think it's a mutual educational process, and there
are some imperatives in the health sector that go beyond local
imperatives and should be strongly suggested at least to the
communities. But by and large I think that what you're implying
is absolutely correct, that the talk has gone all in one direction,
and there hasn't been enough listening in return from the
more central authorities. I hope that this project will find
a way in suggesting ways to take the activities to scale to
achieve these goals, to give much more power and decision-making
authority at the local level where it ought to be.
Geeta Rao Gupta: Just to add one very direct
way in which on our task force we are attempting to get some
input from communities is to have representation among our
task force members of women who head organizations that work
at the grassroots, at the community level, so that we can
listen to their reactions to what we are suggesting, they
can take back what we are talking about, and come back to
us with some inputs. That's one of the ways in which we are
trying to do this. The other thing is just to mention our
next task force meeting is in Nairobi, and far away the Federation
for African Women Education is hosting it, but as part of
the task force, as many of the other task forces have done
as well, agenda we're actually going to be visiting different
projects and visiting with some of the communities in smaller
groups to try and get a sense of whether what we are saying
and asking for has any basis in reality.
Question: I work with journalists in Africa
writing on AIDS, and one of the things I was wondering about—I've
seen so much good that people living with HIV can do in terms
of educating and as an example, what they call in French témoigner
to witness that they have the illness but they're still doing
something, and I wondered what provisions you're making to
give them a place in your programs.
Josh Ruxin: We don't have any specific programs,
because we are a research project. But in the meeting that
we have coming up next month in Rwanda, we're actually going
to have observers who participate in our meeting who are témoigner
and who work with not-for-profit, community-based service
organizations that are addressing that specific issue.
Question: [Inaudible]
Josh Ruxin: Absolutely.
Benjamin Gurman: Yes, my name is Benjamin
Gurman, retired United Nations Development Program. I haven't
heard from any of the panelists a reference to the structural
adjustment program, and getting your economic house in order,
and what was very prominent over the past 15 years, how this
was impacting on the poor, transferred to the poor. This relates
to poverty reduction, this relates to public funds to education
and health. What is your reaction to that program in relation
to what may have to be done on a macroeconomic policy, the
World Bank and some of these other institutions, and the resources
available to public health and education?
Josh Ruxin: One of our research papers is
actually going to be an analysis on the constraints on national
spending on HIV / AIDS and other health priorities which have
results from IMF structural-adjustment programs. I don't have
an answer for you right now, but I'd certainly welcome your
perspectives and thoughts and suggestions about sources to
pursue.
Lisa Anderson: Okay. I think we're ready
to thank this panel and begin our final one.
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