115 looking back in despair: ten years after cairo

7/28/2019 115 Looking Back in Despair: Ten Years After Cairo

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StudiesIndian Journal of Gender

DOI: 10.1177/0971521504012001062005; 12; 115Indian Journal of Gender Studies

Mohan RaoLooking Back in Despair: Ten Years After Cairo

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Looking Back in Despair:

Ten Years After Cairo

MOHAN RAO

Ten years after the International Conference on Population and

Development (ICPD) held at Cairo in 1994, it is a time to take stock.Where do we stand today with respect to the commitments made

by the governments of 179 countries of the world to enhance repro-ductive health and rights? How did the ICPD influence populationpolicies in India? What has happened to womens health and,indeed, to the health of the people in the intervening period?

The Cairo consensus had a complex heritage. Moulding it were

feminist activists, largely from the West, with support from thepopulation control establishment and the World Bank, calling fora new direction to the debate on population and development,one that emphasised reproductive health and rights, and abjureda narrow focus on demographic goals that characterised populationcontrol.

There was a coming together of seemingly opposed groups in

crafting the Cairo consensus. The population control establishment,composed of a wide array of extremely influential actors andinstitutions, ranging from the World Bank and Population Councilto a number of NGOs, nation-states, health personnel and acad-emics (Bandarage 1997), apparently realised that the demographicgoal of reducing fertility could not be attained without taking intoaccount womens ability to make decisions regarding reproduction

and fertility. In other words, even for purely instrumental reasons,there had to be a change in approach to the population issue. Thesewomens rights activists, feminist academics and some health

Indian Journal of Gender Studies, 12:1 (2005)Sage Publications New Delhi/Thousand Oaks/LondonDOI: 10.1177/097152150401200106

Mohan Rao is Professor, Centre of Social Medicine and Community Health,Jawaharlal Nehru University, New Delhi 110 067. E-mail: [email protected].

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activists undoubtedly brought to the fore first world feministconcernsin particular the right to abortion, now sharply threatened.They were united in opposition to Protestant fundamentalists in-creasingly setting the agenda in the USA, who argued that womensrights undermined the family and the community, and were the

bedrock of the anti-abortion movement. Joining the USA were ofcourse the Holy See and some Islamic countries (Petchesky and

Judd 1998).No original sin was committed at Cairo when liberal feminists,

predominantly from the West, went into alliance with the neo-Malthusian population control establishment. Indeed, it was pre-cisely this relationship that had spawned the global populationcontrol movement in the 1950s. However, during the interveningyears, there had been a critical distancing. The fact that a sectionof feminists, referred to by Hodgson and Watkins (1997) as repro-ductive health feminists, were now willing to be fellow travellerswith the World Bank, along with the population control establish-ment, was entirely new. Was this a marriage of multinationalfeminisms with international debt? For what was clear is that oncethe World Bank threw its weight behind the reproductive and childhealth (RCH) approach, indebted countries were quick to follow.

The Cairo consensus has been described as a landmark accord,a turning point in the history of the population field, a sea changein the way population and reproductive health are conceptualised(Haberland and Measham 2002: 124). More frequently, it has beendescribed as a paradigm shift in the way population and develop-ment are understood. Indeed, it has been described as revolution-ary (Cornwall and Welbourn 2002).

Yet in response to the Indian governments country paper at theFourth World Conference of Women at Beijing in 1995, seven all-India womens organisations prepared an alternative documentwhere the ICPD came in for devastating criticism:

The slogan of sisterhood needs to be placed in the contemporaryinternational situation when the so-called developed First World,led by the USA, wants to impose its agenda on the rest of theworld in the name of globalisation ... the direct impact was seenin the recent Conference at Cairo ... where the agendas of the G-7group were pushed through and issues concerning Third Worldwomen were left unaddressed. For instance in Cairo the issue



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Looking Back in Despair: Ten Years After Cairo l117

of abortion dominated the proceedings. The representatives ofmillions of Third World women in Cairo hoped, while supportingthe struggles of Western women for their right to abortion, atleast some attention would be paid to their experience. Insteadthey did not get the support of women representing the FirstWorld.

We strongly believe that where the inequality of nations isincreasing, where the development of the First World is in directproportion to the underdevelopment and exploitation of the ThirdWorld, the slogan of sisterhood would mean to protect the inter-ests of poor women in the Third World and to strengthen theglobal struggle against new forms of colonialism. (TowardsBeijing: Crucial Issues of Concern 1995: 36)

Arguing that issues of development of poor countries in the newglobal order received short shrift at the ICPD, it was also arguedthat the conference did not take adequate note of processes thatgoverned health in third world countries, which, in the currentglobal scenario, were working fundamentally against the interestof the people of the third world in general and women and childrenin particular. The alternative document notes: Womens healthshould not be subordinated to population goals nor restricted toreproductive matters (ibid.: 33).

Ten years down the line, it becomes very evident that thesewomens groups in India showed eerie prescience. The Cairo con-sensus was indeed a step forward, but a terribly modest one atthat. A decade after Cairo, evidence around the world indicatesthat womens health has taken a sharp turn for the worse: life ex-pectations have either stagnated or worsened; infant mortalitydeclines have either plateaued or decelerated; maternal mortalityaround the world remains largely unchanged (in fact, increasingin countries like India); increasing hunger and infectious diseasesare taking their toll; and HIV/AIDS continues to stalk poorcountries in particular, despite the commitment to RCH. While itis indeed true that following the ICPD several countries initiatedsome progressive policy changesChina for instance abandonedits one-child policy, while Nepal decriminalised abortion, and Indiaofficially withdrew targets in the family planning programme,albeit brieflysuch changes have been swept away by the windsof neo-liberal macroeconomic policy.



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That macroeconomic policies pursued uniformly across the globeat the instance of international financial institutions have beendeleterious to health in general and womens health in particularis indisputable. But what is so striking, so startling, is that thecommitment to the RCH approach has made little difference. Whilethe experience of Latin America and Africa is all too well known,that of China and Russia is particularly apposite since they reveala more significant retrogression in the health of women than wouldhave been anticipated. The example provided by China is striking:reforms there have meant an annual real increase in GNP by 9 percent, quadrupling the size of the economy in merely 20 years (Liuet al. 2001). Yet this has been accompanied by increasing incomeinequalities between regions and in sharpening health inequalities

between ruralurban areas, within them and between the sexes.In 1994 the prosperous coastal province of Zhejiang, for instance,had a maternal mortality rate (MMR) of 23.74 per 100,000 live birthswhile the poorer inland province of Quinhai had a figure of 215.37.Infant mortality rates (IMR) stagnated, and in some rural areasincreased. Data on the growth of Chinese children also indicate in-creasing disparities in height between rural and urban areas, and

between boys and girls. Despite the Chinese governments commit-ment to gender equity, the reforms have led to an increase in genderdifferentials in child survival along with increases in morbidityrates among females. The economic changes, along with the onechild per family norm (now officially abandoned), have accentuatedthe problem of missing girls. Poignantly, as in our country, medicalexpenditure is emerging as a leading cause of the impoverishmentof families as the health system collapsed, again particularlyaffecting women and girls. China has now commenced offeringfinancial incentives to encourage the birth of girls, and thus curtailthe spread of bare branches, that is, men with no prospect ofmarriage, that has led to the kidnapping and trafficking of women.

With the collapse of the Soviet Union, the world turned upsidedown for the common people of Russia (Shkolnikov et al. 2001).Levels of unemployment and poverty rose sharply with a two-fold drop in real income and a staggering increase in income in-equalities, even as the social security system and health system,perhaps already ailing, died under the shock treatment prescribed

by the World Bank and the IMF. Between 1991 and 1994, life expect-ancy among men decreased by close to seven years, from 63.6 to



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57.5 years; among women it declined by close to three years from74.4 to 71.1 years. Such a decline in life expectations in populationsnot at war or suffering the onslaught of the other horse of theapocalypse, famine, is historically unprecedented. Unlike China,where rural areas bore the brunt of the reforms, in Russia the citieslargely paid the price. Infectious and communicable diseases thathad disappeared rode on poverty and hunger, extracting a toll,including the innocuous childhood disease, measles. Tuberculosisand AIDS assumed epidemic proportions. A multivariate analysis

revealed that labour force turnover explained a large part of theincrease in death rates. Of the proximate causes, injuries and vio-lence accounted for a third of the overall decline in life expectationwhile cardiovascular diseases accounted for a further quarter. Thethird largest category was alcohol related, accounting for approx-imately 15 per cent of the decline. An interesting finding fromRussia is that while the gender gap in mortality is considerable

in all demographic and socio-economic groups, it is consistentlysmaller for men and women in higher socio-economic positions.In all populations, socio-economic disadvantage increases gendergaps in mortality. This is to say, issues of poverty, of class, tookprecedence over gender. Significantly, the Russian government,concerned with its declining population, has sharply curtailedaccess to abortions, making them almost impossible to obtain. At

the same time, in another pro-natal move, the legal age at marriagefor females has been reduced. Given the depopulation that Russiawitnesses, given, too, the fact that permitting immigration is con-sidered an anathema, in an effort to raise birth rates, the legal ageat marriage has been reduced to an unbelievable 14 yearswithpermission from parents and the local authoritiesand to 16 yearswithout.

The situation in India is deeply troubling. While officially theNational Population Policy (NPP) of 2000 has partially reflectedthe shift in thinking at Cairo, at the grassroots, however, the morethings change, the more they remain the same. One importantreason is the consequence of structural adjustment policies, whichhas further reduced Indias commitment to primary health care,leading to the collapse of the public health system. As the NationalHealth Policy admits, at 0.9 per cent of GDP, India has the worldsfifth lowest spending on health care. While health sector spending



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has shown a secular decline, that for family planning has pro-portionately increased. Even while the Centre was committed tothe Cairo declaration and committed itself to a non-target-orientedprogramme, several state governments announced populationpolicies of their own, some at the behest of an American consult-ancy firm, Futures Group, whose function it has been in the pastto create fears of a population explosion. These state populationpolicies are deeply violative of the NPP, of the commitments madeat Cairo, and include a plethora of incentives and disincentives,including a two-child norm eligibility to contest panchayati rajinstitutions (PRIs) elections.

The irony, of course, is that PRIs are seen as a vehicle of democ-ratisation and a space for the dalits, the adivasis and women tofind a political voice. Indeed, a third of seats are to be reserved forwomen precisely to help empower them politically. But one handof population policy takes away what the other hand of womensempowerment gives.

Health and womens groups approached the National HumanRights Commission (NHRC) in 2002 with a memorandum that thetwo-child norm was discriminatory, anti-democratic and violativeof commitments made by the Government of India in several inter-national covenants. They were, the memorandum said, profoundlyanti-women, anti-dalit, anti-adivasi and indeed anti-children (Rao2002). The NHRC in response issued orders to the concerned stategovernments, and, at a National Colloquium on 9 and 10 January2003 attended by representatives of these state governments, issueda declaration.

This NHRC declaration

notes with concern that population policies framed by some StateGovernments reflect in certain respects a coercive approachthrough use of incentives and disincentives, which in some casesare violative of human rights. This is not consistent with thespirit of the NPP. The violation of human rights affects, in parti-cular the marginalised and vulnerable sections of society, includ-ing women.... [F]urther that the propagation of a two-child normand coercion or manipulation of individual fertility decisionsthrough the use of incentives and disincentives violate the prin-ciple of voluntary informed choice and the human rights of thepeople, particularly the rights ofthe child. (NHRC 2003: 1)



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Yet, on 30 July 2003, the Supreme Court of India upheld theHaryana government law mandating the two-child norm for con-testants to panchayat elections. Interestingly, while the SupremeCourt spoke about the torrential increase of population, earlierthe Rajasthan High Court judges, hearing a similar set of petitions,in their ruling argued:

These provisions have been enacted by the legislature to controlthe menace of population explosion.... The government is spend-

ing large sums of money propagating family planning. One ofthe agencies to which the project of family planning has beenentrusted for implementation is the gram panchayat. The panchesand sarpanches are to set the example and maintain the norm oftwo children. Otherwise what examples can they set before thepublic? (Sarkar and Ramanathan 2002: 42)

Not surprisingly, this ruling has met with widespread middle-classsupport in the country.

But this is, of course, a red herring. Despite population growth(which is declining substantially in almost all parts of the world),per capita food production increased by nearly 25 per cent between1990 and 1997. The per capita daily supply of calories rose fromless than 2,500 to 2,750, and that of proteins, from 71 to 76 g. In

other words, not one person in the world needs to go to bed hungry.Yet, given the fact that the overall consumption of the richest fifthof the worlds population is 160 times that of the poorest fifth, 840million people worldwide, 160 million of them children, are under-nourished. Close to 340 million women are not expected to surviveto the age of 40.

The overpopulation argument also elides the fact that there

occurs a net transfer of close to $200 billion annually from the coun-tries of the South to those of the North. Indeed, this figure hasincreased substantially over the last three decades. During thisperiod, when a number of countries have implemented structuraladjustment programmes, inequalities within and betweencountries have risen sharply: the income gap between the worldsrichest and poorest has more than doubled. In 1960, 20 per cent ofthe worlds people in the richest countries had 30 times the incomeof the poorest 20 per cent; today they command 74 times more.



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The same richest 20 per cent of the population command 86 percent of the world GDP while the poorest 20 per cent command amere 1 per cent. More than 80 countries have per capita incomeslower than they were a decade or more ago. It is not surprisingthen that the past decade has been described as the lost decade.

With the onset of neo-liberal policies in India, employmentgeneration, especially for women, has fallen sharply, with an evengreater increase of casualisation of the female workforce than

before the reforms (Unni 2001: 236066). A study by the NationalCouncil of Applied Economic Research (NCAER) concluded thatfeminisation of labour, and thus of poverty, is a reality across thecountry, and that the decline of rural non-agricultural employmentin the 1990s has increasingly pushed women back into agriculture.This study also reveals the increasing participation of femalechildren in wage labour (Shariff 1999: 74). Perhaps most importanthave been the policy changes that have impinged on food securityfor households. Even as the country sits on a mountain of unsoldfoodstocks of the range of 63 million tonnes, the per capita avail-ability of food grains has come down drastically from 177 kg in199192 to 152 kg in 20002001; cereals have declined from 162.8 kgin 199192 to 142.8 kg in 20002001 and pulses from 14.2 kg in199192 to 9.6 kg in 20002001. There has also been a decline in theoff-take from the public distribution system (PDS), partly as aconsequence of targeting, and partly because of declines inincomes. Thus, per capita calorie consumption has also declined.Given increasing inequalities, this could only imply an increase inhouseholds unable to meet their basic food requirements (Patnaik2002). At the same time, tax GDP ratios declined from 13 per centin 199091 to 9 per cent in 20002001, even as the governmentpleaded paucity of funds for social sectors.

It is in this context that the National Family Health Survey (NFHS)shows that the MMR has increased between 199293 and 199899from 424 to 540 per 100,000 live births (IIPS 2000: 195). It is in thiscontext, too, that the rate of decline of the IMR has significantlyslackened in the last decade: in the decades 197181 and 198191the percentage decline in IMR was more marked than in the period199199. The percentage decline in IMR between 1971 and 1981was 14.7; between 198191 it was even more marked at 27.3 percent. However, in the period 199199, there was a marked stagnation,with the rate of decline in the IMR at 10 per cent. While there has



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been a decline in the under-5 mortality rate (U5MR), the pace ofdecline has come down and is currently hovering around 95.During 197181, the percentage decline was 20.6. The decline wasmuch sharper during the 1980s, with a percentage decline of 35.7.However during the 1990s with the onset of policies of liberal-isation, the rate of decline was reduced to 15.1 per cent (Misra etal. 2003).

Despite the slight overall improvement in the sex ratio, the childsex ratio (CSR) in India as a whole has declined significantlyfrom 945 in 1991 to 927 in 2001. It is estimated that there are 35 mil-lion missing females in India as per the 2001 census (Patel 2004).This decline in the CSR has been particularly notable in HimachalPradesh (897), Punjab (793), Chandigarh (845), Haryana (820) andDelhi (865), better-off regions in the country. In all these states,referred to as the Bermuda triangle for missing females, the numberof female children per 1,000 male children in the 0 to 6 years agegroup declined by more than 50 between 1991 and 2001. Gujaratand Maharashtra have also joined this group of states.

A part of the declining CSR is due to continuing anti-femalerates of infant and child mortality. But, more significantly, therehas also been a marked masculinisation of the sex ratio at birth(SRB). In India a figure of 105 male births for 100 female births isconsidered the norm. However, estimates of the SRB for 1998reveals an all-India figure of 111 males per 100 females (Premi 2001:187580). This is indicative of sex-selective abortion (SSA) of femalefoetuses on a truly massive scale. Figures above this nationalaverage of the SRB are seen in Gujarat (113.9), Haryana (123.3),Punjab (122.8), Rajasthan (114.8) and Uttar Pradesh (118).

Health care costs have increased remarkably over the 1990s, evenas health sector reforms under the aegis of the World Bank havemeant increasing privatisation. Thus, the rate of untreated ailmentsincreased by 40 per cent for the poorest expenditure decile; andthose not accessing health care due to financial reasons increasedfrom 10 to 20 per cent in rural areas and 15 to 25 per cent in urbanareas (Sen et al. 2002: 281312). Indeed, health expenditure is emerg-ing as one of the leading causes of indebtedness in the country(Krishnan 1999).

In sum, then, the years since the ICPD have largely seen negativechanges in health indices, in the Indian states commitment to thehealth of the people, and indeed to RCH itself enunciated at Cairo,



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along with a huge increase in different forms of violence againstwomen, including SSA. Meanwhile, targets have been introducedagain into the family planning programme, which now boasts of aslew of incentives and coercive disincentives.

At the same time, over this period right-wing fundamentalistsensconced in power in the USA have increasingly cast their shadowthrough such measures as the global gag rule, forbidding USfunding for family planning programmes that have legalisedabortion and restricting access to condoms under AIDS program-mes in favour of abstinence. At the same time, too, the position ofthe Holy See in the United Nations has been enhanced.

As national governments, NGOs, donors and UN agenciesprepare to look back at Cairo, it is a matter of great regret, if notshame, that a section of feminists in the West have decided not toengage with organisations of the UN to prevent a rollback of thegains made at Cairo. Some organisations, supposedly represent-ing women of the South, have also endorsed this position. Havethey betrayed, again, the slogan of sisterhood? When the worldsonly global superpower is destroying all institutions of globalgovernance, it is astonishing that these groups decide to indirectlyendorse the stand of the US. These are issues on which womensgroups and health groups in Indiahome to the largest of suchmovements in the worldhave to take a stand. Do we ask fordemocratisation of global governance? Do we engage with the UNsystem? Do we defend Cairo? Do we serve notice on our nationalgovernment? That enough is enough?

References

Bandarage, A. 1997. Women, Population and Global Crisis: A Political EconomicAnalysis. London: Zed Books.

Cornwall, Andrea and A. Welbourn. 2002. Introduction, in A. Cornwall and A.Welbourn (eds.), Realizing Rights: Transforming Approaches to Sexual andReproductive Well-being, pp. 120. London: Zed Books.

Haberland, Nicole and Diana Measham (eds.). 2002. Responding to Cairo: CaseStudies of Changing Practice in Reproductive Health and Family Planning .New York: Population Council.

Hodgson, Dennis and Susan Cots Watkins. 1997. Feminists and Neo-Malthusians:

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Krishnan, T.N. 1999. Access to Health and the Burden of Treatment in India: An

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Patnaik, Utsa. 2002. Food Stocks and Hunger. Paper presented at the GadgilMemorial Seminar, Centre for Economic Studies and Planning, JawaharlalNehru University, New Delhi.

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