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George A. O. Alleyne
Chancellor, University of the West Indies
June 29, 2006
Sexual and Reproductive Health in the Search for Development
(Port-of-Spain, Trinidad and Tobago)ﳰan>
First, I must thank Dr. Jacqueline Sharpe for the invitation to address you on this occasion marking the fiftieth anniversary of the Family Planning Association of Trinidad and Tobago. I accepted the invitation not only because of the importance of the Association and what it does, but principally as a tribute to Dr. Sharpe. It gives me the opportunity to congratulate her publicly and express my pride at her elevation to the presidency of the International Planned Parenthood Federation. Her election is obviously a mark of recognition of the esteem in which she is held by her international peers and colleagues and a signal honor not only for her, but for all of us in the Caribbean. And of course I cannot help but seek to have some of the kudos rub off on our University of the West Indies of which she is a proud graduate. I wish her a long and productive presidency and am sure that she will have much better luck than another distinguished Barbadian who once presided over another Federation.
I must also congratulate the Trinidad and Tobago Family Planning Association on reaching its fiftieth anniversary. This history must be a reflection of the dedication of hundreds of committed individuals as there are not many health related non-governmental organizations which preserve their vibrancy and last this long. This longevity must also mean that it is filling a need and playing an essential role in the life and health of Trinidad and Tobago. I was pleased to note the extent of its outreach activities and the focus on providing services especially to those who could not normally afford them.
This Association has always had family planning in its title, but it is clear that from the beginning the programs dealt with family planning broadly and not only with contraception. The history of family planning is of considerable interest and I will use the development of thinking and practice in this area to illustrate how now we must think of the whole field more generally. Indeed, we speak more now of sexual and reproductive health and the burden of my comments will relate to how this has developed out a context of family planning and the relation of this aspect of health to various development paradigms and goals. The changes in this field are almost a mirror of the major societal changes that have taken place and the shifts in the perception of the role of women in society.
It was some ninety years ago that an American nurse-Margaret Sanger had the courage to open a family planning clinic in Brooklyn, New York[1]. It is a matter of record that the clinic was closed in ten days, not just by the police, but by the New York Vice Squad and that in itself gives an idea of how the activity was perceived. Of course she persisted and across the Atlantic the famous English feminist, Marie Stopes followed suit.
But their struggle must be seen not only as a matter of informing about contraception, as knowledge of contraception is as old as history although the methods were not widely available. The activities of these women in family planning represented another shot in the battle against gender inequality and a statement in the health field for the rights of women-rights which were being contested in other areas as well.
The technology available to Margaret Sanger and Marie Stopes was really quite primitive, although numerous ingenious contraceptive methods had been used through the years. I have read that there is a museum of contraception in Toronto[2] which even has among its exhibits a sheath that the Earl of Condom made for the amorous King Charles the Second. I am not sure if he was knighted after Charles used the device and found it to be satisfactory. I was intrigued by some of the prescriptions. Let me cite some.
㣯rding to an ancient medical manuscript called the Ebers papyrus (150 BC) women were advised to grind together dates, acacia (a tree bark) dip seed wool into the sweet gel and place it into the vulva. As primitive as this sugary mix appears, it was usually effective. Acacia eventually ferments into lactic acid-a well known spermicide.
Pessaries appeared in the second century. They were made of many different substances including elephant and crocodile dung.奄
The Planned Parenthood Federation of America has produced a fascinating history of birth control methods which shows the interplay of courage, money, ingenuity and technology[3]. There must be few substances that have not been tried at one time or another to prevent conception. The history is also a story of how the acceptability and the technology accompanied progress in women͉ rights and empowerment. It still amazes that not so long ago physicians were allowed to prescribe condoms for men to use in extra but not intra marital intercourse. Some sociologists claim that the central issue in condom use anyway is that it is usually a decision made by males and reflects a gendered perspective on prevention. It is not that women do not know about condoms, but the difference in power gives to the male the say in whether they should be used or not.[4]
As the history of the Trinidad and Tobago Family Planning Association and its homologues will show, widespread knowledge and practice of family planning in the Caribbean is of relatively recent vintage. Even if she would have known about it, the idea of contraception would have been anathema to my grand mother who had thirteen children. I am the first of seven children and I always recall my motherಡther apologetic announcement to us that she was pregnant with her seventh child. Had my father not died soon after it is possible that I would have had more than six brothers and sisters. In those days the words of Psalm 127 were taken almost as a command.
㠡rrows are in the hand of a mighty man;
So are children of the youth.
Happy is the man that hath his quiver full of them:奄
Note of course that there is no mention of the womanਡppiness. But neither I nor my siblings have more than three children. My generation wondered why their parents either did not know or for various reasons, usually religious, were reluctant to use contraception and I cannot help believing that much of this was a long hangover from the Christian hostility in the middle Ages to sexual pleasure without reproduction.
The decade of the fifties saw the establishment of family planning associations that began rather timidly to make services widely available-Barbados in 1954, Trinidad and Tobago in 1956 and Jamaica in 1957. It must have taken quite some courage to venture into this area at that time, as the founders were dealing with a very sensitive subject and there would have been overt or covert opposition by organized religion.
It has been suggested that over the course of the years we have seen essentially three reasons for promoting contraception as one of the offerings of family planning programs[5]. First there was the demographic rationale which was related to the need to slow population growth and indeed, there has never been lack of enthusiasm for the Malthusian apocalyptic view which is still mentioned when we observe the steady increase in the numbers of human beings on our planet. Between 1800 and 1930 the world͉ population increased from 980 million to 2.1 billion. In 1960 it was 3 billion, in1974, 4 billion, in 1987, 5 billion and in 2000, 6 billion. Most of this increase is taking place in the developing countries and in the decade of the fifties there would have been concern that population growth in islands with limited space would frustrate any efforts at economic growth.
Then there is the fertility rationale that relates to health and economic considerations. There is no doubt that female fertility falls as countries progress economically. The temporal relation between the decline in fertility which is preceded by a fall in child mortality creates a demographic bulge which, if taken advantage of, can contribute to a countryॣonomic growth. This demographic bulge or demographic dividend has been posited to be partly responsible for much of the rapid economic growth of the prosperous East Asian countries[6]. It has always been a topic of debate whether the fall in fertility is causally related to the decrease in child mortality or if there are external factors which contribute to both. There are some experts who propose that couples who regard children as insurance for old age, or a resource that increases the family௵tput of goods and services, deliberately limit their families when they see that fewer of their children die at an early age.
The third rationale and perhaps the one which now has greatest currency is based on human rights. Reproductive health is being cast as a matter of rights and both sexes have rights to the various aspects of sexual and reproductive health. The sexual and reproductive health of women encompasses their empowerment and their right to reproduce when and if they wish.
I would add another reason which I know to have been operative in Barbados and that is consideration for the poor maternal health consequent on multiple pregnancies in rapid succession. Maurice Byer has told the dramatic story that as Chief Medical Officer of Barbados he took Prime Minister Grantley Adams to see some multiparous women in an effort to persuade him that the Government of Barbados should support family planning. The women cried out to him that multiple pregnancies were not good for their health or the health of their children. Mr. Adams was convinced by seeing women who had aged prematurely, weak from the anemia of multiple pregnancies and legs disfigured by bulging varicose veins. He heard their tragic stories of not wanting so many children, but not knowing what to do. According to Dr. Byer who was one of the small group of intrepid persons who formed the Barbados Family Planning Association in 1954, the Prime Minister went to Parliament the next day and introduced legislation supporting family planning.
At age 50 your Association is operating in an environment which has been shaped by two major events. The first was the International Conference on Population and Development in Cairo in 1994, the second has been the universal acceptance of the Millennium Development Goals in 2000. These events have cast sexual and reproductive health as a matter of global and national human development.
The Cairo Conference and its Programme of Action[7], in line with previous similar conferences saw population issues as critical for development as measured by economic growth. To cite from the Programme:
襠 population and development objectives and actions of the present Programme of Action will collectively address the critical challenges and interrelationships between population and sustained economic growth in the context of sustainable developmentnd it goes on: nsified efforts are needed in the coming 5, 10 and 20 years, in a range of population and development activities, bearing in mind the crucial contribution that early stabilization of the world population would make towards the achievement of sustainable development쯩>
The size and distribution of population were of major concern. Would the earthಥsources be sufficient to support the increasing numbers and would the urban drift of population create mega cities that could not provide the basic services needed for a decent life? But of even greater concern was the evidence that most of the increase in population was taking place in the developing countries, which by definition were less able to support it. The developing countries were into a vicious spiral of increasing numbers that were a cause of and contributed to under-development as measured by lack of economic growth.[8] But in addition, it did not escape the Conference that environmental degradation was an almost natural consequence of the increased population in the poor countries of the South. Thus development as seen both in terms of sustainability of environmental resources and economic growth would be compromised by increased population, hence the emphasis on fertility control.
The Conference set out 14 guiding principles which as was to be expected contained the affirmation of the entitlement to the rights and freedoms of the Universal Declaration of Human Rights. As was done at the Rio Conference a few years before, it put human beings at the center of concerns for sustainable development and affirmed the right to that development. The Principles also spoke to the right to health as the 駨t to an adequate standard of living for themselves and their families, including adequate food, clothing, housing water and sanitation쯩>
But the Cairo Conference was a landmark event and has shaped the work and discourse of family planning all over the world because it went beyond considering development in the context of demography. It recognized and advocated the rights of women to sexual and reproductive health. As Thoraya Obaid, the current Executive Director of UNFPA put it in a speech marking the tenth anniversary of Cairo:[9]
襠Cairo Programme of Action helped governments to move away from a narrow focus on family planning to a new concept of sexual and reproductive health throughout the life cycle. The Cairo agenda changed the international debate about population from human numbers to human beings쯩>
Reproductive health was defined as follows:
ate of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. It also includes sexual health, the purpose of which is the enhancement of life and personal relations쯩>
But the Principle which in my view has had the greatest resonance and guides much of the work in this area states:
䶡ncing gender equality and equity and the empowerment of women, and the elimination of all kinds of violence against women, and ensuring womenࡢility to control their own fertility, are cornerstones of population and development 嬡ted programmes. The human rights of women and the girl child are an inalienable, integral and indivisible part of universal human rights.奄
Thus reproductive health is seen as including healthy sex as important in and of itself as well as health in relation to matters of reproduction. Reproduction cannot be the only objective of sexual health. Sexual health is important for our well being and sexuality must be seen as an essential part our humanity. In addition, the empowerment of women and their ability to control their fertility through access to sexual and reproductive health services represent the main route to control of the population size which is seen as critical for development as it is defined primarily in economic terms. This focus has remained, as at the Cairo plus 10 UN Conference the relevance and importance of the concepts of Cairo were reaffirmed.
The World Health Organization defines five core aspects of reproductive and sexual health care; improving antenatal, perinatal, postpartum and newborn care; providing high quality services for family planning, including infertility services; eliminating unsafe abortion; combating sexually transmitted infections including HIV, reproductive tract infections, cervical cancer and other gynecological morbidities; and promoting sexual health.[10] I have always questioned why these services include no mention of the sexual health problems that affect men, as I presume that good sexual health is as important to men as it is to women.
The second major event was the adoption of the Millennium Development Goals five years ago by the United Nations as the benchmark against which the world would measure progress towards the kind of development that in the words of Eric Williams has the face of man. The first of these is the eradication of extreme poverty and hunger. As the Secretary-General of the UN, Kofi Annan would say[11]:
襠 Millennium Development Goals, particularly the eradication of poverty and hunger cannot be achieved if questions of population and reproductive health are not squarely addressed. And that means stronger efforts to promote womenghts and greater investment in education and health, including reproductive health and family planning.奄
Other Goals include the promotion of gender equality and the empowerment of women, the improvement of maternal health and combating diseases such as HIV/AIDS, tuberculosis and malaria. The specific target with relation to HIV/AIDS is to have halted and begun to reverse the spread of the disease by 2015.The relation of all of these to sexual and reproductive health is immediately obvious. In the case of HIV/AIDS which is predominantly a sexually transmitted infection, the methods advocated for its control are almost the same as have been promoted as good sexual and reproductive health practice. Even the MDG that speaks to ensuring environmental sustainability is relevant, as one of the rationales of population control or stabilization is to ensure that that we do not overuse the worldtural resources and thus compromise the capacity of future generations to enjoy them.
To what extent do these changes in focus of sexual and reproductive health affect the philosophy and work of family planning associations in the Caribbean and especially here in Trinidad and Tobago? There is no doubt that the excessive population growth which was a major concern of fifty years ago no longer presents the same threat or challenge. The fertility rate in children per woman is 2.1 in the Caribbean and 1.6 here in Trinidad and Tobago-a level that has been constant at least for the past five years[12]. Indeed countries that have a fertility rate below the replacement rate of 2.0 are beginning to be concerned.
Thus, the focus in many cases has shifted to embrace other aspects of sexual and reproductive health. I was pleased to note that this Association includes among its core services include not only directed to women, such as screening for cervical and breast cancers but also offers prostate examinations. Thus it takes seriously the notion that sexual and reproductive health involves both sexes. But there is one area in which I see the Association playing an ever increasing role, and that relates to gender inequality and the empowerment of women as postulated as a Millennium Development Goal. We are increasingly concerned by the growing feminization of the HIV/AIDS epidemic and much of this relates to the status of women in our society and the extent to which there is under-appreciated gender discrimination. Throughout the Caribbean one receives reports of older men abusing young girls and young women not being able often for economic reasons to enjoy sexual health and determine their reproductive destiny.
Associations like yours will have an increasing role to play in the educational reforms that make both females and males aware of their own sexuality and sexual responsibility at an early age. We know that awareness of sexuality does not go hand in hand with knowledge about the responsibilities that go with it. Data from several Caribbean countries show the early age of sexual activity among children, with which goes the increased probability of damaging their sexual health, including exposing them to the risk of sexually transmitted infections, of which the deadliest is HIV/AIDS. I was pleased to hear the Minister of Health at the recent UN General Assembly spell out the programs being developed here and striking a balance between the various approaches to prevention in addition to scaling up treatment of those who are HIV positive. I note your Association०forts in the field of testing and counseling for HIV/AIDS.
Madam Chair, associations like yours have to evolve or die. I am pleased to note the evolution from one that was focused mainly on fertility control to one that is in the mainstream of the efforts in sexual and reproductive health.
Thus I was particularly cheered by the emphasis you have placed on sex education broadly conceived, and you have charted an excellent course when you stated:
堩ntend to provide sexual and reproductive health services for adolescents that recognize their rights to information, education and services, privacy, confidentiality, respect and informed consent.鯵 went on to say, 堡re committed to a way forward that reaffirms a rights-based approach to sexual and reproductive health쯩>
From this kind of statement one can be assured that your Association is evolving and runs no risk of fossilization.
As we have seen, fertility control can be linked directly to sustainable development but that is no longer the overriding concern here. I believe that the approach which sees sexual and reproductive health more broadly is equally critical for development and if we wished any proof we simply have to consider the accepted and acknowledged role of this field to the Millennium Development Goals which have been 쯢ally accepted as benchmarks of broader progressԨese goals when taken together with their targets represent the most ambitious effort yet to seek genuine human development in our time. It is fair to say that no countries in the world will achieve these goals, to which they are all formally committed, except they pay serious attention to the sexual and reproductive health of all their citizens.
I have no doubt that the commitment to these goals is alive and well in Trinidad and Tobago.
I thank you.
Keynote Address at the Fiftieth Anniversary meeting of the Family planning Association of Trinidad and Tobago. June 29, 2006
[1] Margaret Sanger-Wikipedia, the free encyclopedia. http://en.wikipedia.org/wiki/Margaret_Sanger
[2] Petrick W. The Hall of Contraception http://desires.com/1.6/Sex/Museum/museum1.html
[3] Planned Parenthood Federation of America, Inc.-A History of Birth Control Methods
http://www.plannedparenthood.org/pp2/portal/files/portal/medicalinfo/birthcontrol/fact-020709-contraception
[4] Kreiger N, Fee E. Man made medicine and womenਥalth: the biopolitics of sex/gender and race/ethnicity. Int. Journal of Health Services.24;265-283: 1994
[5] Levine R., Langer A., Birdsall N., Matheny G., Wright M.,and Bayer A. Contraception. Chapter 57. in Disease Control Priorities in Developing Countries, Second Edition. Eds Jamison D et al. Oxford University Press and the World Bank. 2006
[6] Bloom DE, Canning D, Jamison DT. Health , wealth and welfare. Finance and Development 41(1) 10-15: 2002
[7] Programme of Action of the International Conference on Population and Development.
http://www.unfpa.org/icpd_poa.htm
[8] Birdsall N, Sinding S. Population Matters: demographic change, economic growth and poverty in the developing world. Oxford University Press. New York
[9] Obaid T. The Road from Cairo-Statement at the European Population Forum. 12 January 2004
http://www.unfpa.org/news/news.cfm?ID=407&Language=1
[10] World Health Organization. Reproductive health strategy. Adopted by the 57th World Health Assembly May,2004
[11] Statement by Mr.Kofi Annan, Secretary-General of the United Nations. http://www.unfpa.org/news/news.cfm?ID=39&language=1
[12] Pan American Health Organization. Health Situation in the Americas. Basic Indicators.2005
