STATUS OF WOMEN COMMISSION HOLDS PANEL DISCUSSION ON WOMEN AND HEALTH

Press Release
WOM/1104

STATUS OF WOMEN COMMISSION HOLDS PANEL DISCUSSION ON WOMEN AND HEALTH

Mainstreaming a gender perspective into national health care systems required broad changes in attitudes and awareness by all actors, experts told the Commission on the Status of Women this morning as it held a panel discussion on women and health.

Prof. Stephen Matlin, Director of Human Resources of the Development Division of the Commonwealth Secretariat in London, said that the mainstreaming of gender into health services was not just about offering more women's services. There was a need to correct gender biases in the health field and that required fundamental changes in behaviour on everyone's part. Success in implementing a gender perspective only came when leaders at the highest levels put their energies into change. Countries needed to design health policies and programmes which required understanding by all actors involved, not just the health experts.

Health services for women should be seen as ends not as means, said Dr. Mahmoud Fathalla, Professor of Obstetrics and Gynaecology at Assiut University in Egypt. Often health systems were limited to addressing major health problems instead of preventive care. While the world needed to make basic health care accessible to women, there was more needed in health care systems. There was a need to look at health care with a women's lens. The system needed to change from a "his system" to a "her system" -- they need to change from being hyper-medicalized and impersonalized to being more human and equitable.

Dr. Sandra Dean-Patterson, Coordinator of Health Social Services, Sandilands Rehabilitation Centre, Ministry of Housing and Social Development of the Bahamas, said that there was still the belief that women were the second sex and that men were the leaders. Given that distorted societal lens, health-care policies had also been distorted. Too many women fell through the institutional cracks because the root causes of their problems were never addressed.

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Speaking on the topic of violence against women, Dr. Peter Piot, Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS), said that most countries had failed to address that issue and its impact on the spread of AIDS. While the scale of violence against women and girls was frightening, so was the spread of HIV/AIDS among those who were assaulted. Male violence against women may be illegal, but it was still considered an acceptable part of life in many societies. It was sometimes seen as acceptable by their victims as well.

The Commission will meet again at 3 p.m. today to continue its consideration of women in health. In that regard, it will hear presentations by Dr. Gro Harlem Brundtland, Director-General of the World Health Organization (WHO), and Dr. Nafis Sadik, Executive Director of the United Nations Population Fund (UNFPA). Following that, the Commission will resume its general discussion on the follow-up to the Fourth World Conference on Women.

Commission Work Programme

The Commission on the Status of Women met this morning to consider "Follow-up to the Fourth World Conference on Women: implementation of strategic objectives and action in the critical areas of concern: women and health". The Commission planned to hold a panel discussion and dialogue on women and health.

A report of the Secretary-General on the thematic issues before the Commission (document E/CN.6/1999/4) contains a summary of the results of two expert group meetings convened by the Division for the Advancement of Women of Department of Economic and Social Affairs in 1998. The meetings focused on the critical areas of concern -- one meeting was on women and health, the other was on institutional mechanisms for the advancement of women.

The meeting on "women and health" focused on mainstreaming gender into the health sector. It also addressed such topics as: reproductive health, mental health, environmental and occupational health, and infectious diseases. The expert group meeting adopted specific recommendations with regard to those sectoral women's health issues. It also developed a framework for a gender- sensitive health policy.

The Platform for Action identified "women and health" as one of the critical areas of concern and defined five strategic objectives, as follows: increase women's access throughout their life cycle to appropriate, affordable and quality health care, information and related services; strengthen preventive programmes that promote women's health; undertake gender-sensitive initiatives that address sexually transmitted diseases, HIV/AIDS, and sexual and reproductive health issues; promote research and disseminate information on women's health; and increase resources and monitor follow-up for women's health. In doing so, it also emphasized the importance of a holistic and life-cycle approach to women's health. The Platform for Action reiterated the agreements reached at the International Conference on Population and Development (ICPD) in Cairo, in 1994, in particular with regard to women's reproductive health and rights and added new ones, addressing the right of women to control all aspects of their health, and the relationship between women and men in sexual relations.

Inattention and neglect of women's health issues, in particular reproductive health, in the legislative and regulating frameworks of countries, have been recognized as part of a systematic discrimination against women, the expert group found. Issues linked to women's health and human rights go beyond reproductive health and became visible when increased attention was paid to the widespread incidence of violence against women in all its manifestations, which has a human rights and a health dimension.

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In regard to sexual and reproductive health, the expert group recommends that Governments and international organizations should give priority to research on development of female controlled methods, including microbicide, post-coital/emergency contraception and dual methods that protect both against STDs and HIV and unwanted pregnancy; and methods of male contraception. They should also encourage social and anthropological research in order to evaluate the real needs of women, the factors influencing their behaviour, and their degree of satisfaction as to the services provided and ensure the implementation of the Beijing Platform for Action with respect to the problem of unsafe abortion.

Also in relation to sexual and reproductive health, Governments should:

-- Address the reality and consequences of unsafe abortion by revising and modifying laws and policies which perpetuate damage to women's health, loss of life and violation of gender equality in health care;

-- Integrate sexual and reproductive health services, including screening of genital cancers and treatment for menopause, to respond to the broad health needs of users; and

-- Develop policies and formulate legal tools to support activities aimed at eliminating the practice of female genital mutilation (FGM) and other harmful practices and prevent their medicalization.

In regard to tuberculosis, malaria and other disease control programmes, the expert group recommended that Governments should: ensure that stigmatization (in leprosy, filariasis, HIV and STDs infections) does not lead to under-detection and lack of treatment, especially for women; avoid all forms of compulsory testing for HIV on women, including those related to prevention of mother to child transmission; improve sexual and reproductive health services available to women with HIV and AIDS; and they should improve accessibility to antenatal care and its quality of care for all women, including pre- and post-counselling services associated to HIV testing and avoid all forms of discrimination against women living with HIV.

Also on disease control, the expert group said that health workers and professionals should: encourage their patients to inform their partners, in case of HIV infection, so as to protect them from infection and counsel them as to ways of doing so; encourage families to ensure that all girls and boys are fully immunized and monitored and treated for childhood diseases.

In regard to mental health, the expert group found that Governments should:

-- Invest in educating communities about the effectiveness of mental health interventions and make available the necessary services tailored to the

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different needs of women and men (for instance, treatment for civil and domestic trauma and injury, psychiatric illness, substance use); priority should be given to mental health care as an integral part of primary health care;

-- Encourage systematic efforts to improve the amount and quality of mental health training for workers at all levels, from medical students to graduate physicians, from nurses to community health workers; and

-- Encourage efforts to document the use of psychoactive substances by both women and men and the relative different causes and effects; that should lead to parallel efforts in developing effective approaches to prevent and treat such use.

On occupational and environmental health, the expert group recommends that Governments and international development agencies increase their support of research, particularly in developing countries, on occupational and environmental health risks. That should include risks in the household and from environmental chemicals, and appropriate interventions, including necessary legislation, to reduce environmental and occupational health risks in both urban and rural settings. They should also undertake gender analysis of various sectoral policies to establish health and environment risk profiles for women and men.

Governments should also extend environmental and occupational health policies to cover informal and agricultural sector workers who are mostly women and who are often not covered by protection laws, labour laws or occupational health and safety regulations.

On mainstreaming the gender perspective in health care, medical education and research, the expert group recommended that Governments, professional associations and other institutions should ensure that:

-- Health professionals are educated in human rights as part of their training in health care ethics to ensure that clients are treated with respect, dignity, privacy and confidentiality;

-- Health personnel with the requisite skills are strongly encouraged to enter the specialty of their choice irrespective of their gender, even though it could require support in the form of child care or a scholarship.

Governments, medical authorities and other health professions should ensure that women are given information about the choices available to them, for example, with respect to breastfeeding or contraceptives, the risks and benefits involved, and the freedom to decide which action to take; and that women are not deprived of their right to health services on the basis of conscience clauses cited by health providers.

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In regard to health reform and financing, the expert group said that Governments should secure funds to protect the health of the most vulnerable population groups, particularly poor women throughout their life span. A social pact should be established between the State and all interested parties to guarantee a minimum package of services to cover the health care of those vulnerable groups; they should also ensure that health reform be based on the human right to health and not only on economic criteria.

On creating a framework for designing national health policies with an integrated gender perspective, the expert group found that a series of efforts have been undertaken in that regard. The Commonwealth of Independent States (CIS) has been pioneering the introduction of Gender Management Systems (GMSs), both at the level of the national government and within the health sector in member states. Adapted to the specific conditions and requirements of each country, GMSs are an effective tool for mainstreaming gender within policies and programmes.

An annex to the Secretary-General's report discusses a framework for designing such a national health policy. It states that the shift towards a gender perspective was an important step forward. However, it has not yet delivered the expected results and two main reasons for that can be identified. First, there has been considerable confusion about the terms being used. For example, what is meant by "gender" and why is it different from "sex"? And how is the gender approach different from one that focuses only on women? Those are important issues that need to be properly understood by all those involved in the implementation of gender-sensitive health policies. Second, there has been a lag in the development and dissemination of appropriate techniques for the incorporation of gender issues into policy process. If gender equality is to be a major goal in the development of health services, those involved need to be properly informed about the most effective means by which this can be achieved.

The annex also discusses such topics as: clarifying the concepts of sex, gender and health; gender bias in research; mainstreaming gender in health research, mainstreaming gender in health service delivery; and intersectoral collaboration for gender equality and health.

On the critical area of concern "institutional mechanisms for the advancement of women", the meeting considered the role of national machineries in mainstreaming gender in all programmes and policies at the national level. The meeting also addressed the relationship of national machineries with civil society and the accountability of governments for gender mainstreaming. The meeting also endorsed a sample project to strengthen national machineries, to be carried out by the Division for the Advancement of Women. It requested the Secretariat to summarize the "best practices" described in the experts' papers, in order to provide governments and national machineries with practical examples.

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The Platform for Action states that in order to be effective, national machineries should be located at the highest possible level of government; they should involve non-governmental organizations, and have sufficient human and financial resources and the opportunity to influence development of all government policies. While the Platform for Action provides a very broad and comprehensive mandate for gender mainstreaming, the role and responsibilities of national machineries in translating this conceptual approach into practice are less known and differ from country to country.

The expert group meeting on the topic made a number of recommendations to governments on how to strengthen their national machineries. Among those recommendations are that they should:

-- Locate the gender coordination unit at the highest level of government, falling under the responsibility of the President, Prime Minister, or Cabinet Minister. That would give the national machinery the political authority needed for its mandate of coordinating the mainstreaming process across all ministries.

-- Ensure that senior management in each ministry or agency takes responsibility for integrating a gender perspective in all policies. For that purpose, ministers should ensure that senior managers get appropriate assistance from gender experts or gender focal points.

--Create separate structures for the promotion of gender equality in personnel policy to avoid confusion with the gender mainstreaming functions of the national machinery.

The expert group also said that governments should ensure sustainable financing of national machineries through national budgets and that national machineries were staffed at adequate levels with appropriate seniority, relevant qualifications and gender expertise. A clear mandate was a prerequisite for the efficient functioning of national machineries. The national machinery at the governmental level is a catalyst for gender mainstreaming not an agency for policy implementation.

National machineries should undertake the following functions:

-- Ensuring appropriate gender training for top-level government management and encouraging gender training at all levels of government;

-- Developing methods and tools for gender mainstreaming such as gender impact assessment, guidelines for gender training, and for gender audit across all government activities;

-- Collecting and disseminating best practice models of gender mainstreaming;

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-- Coordinating the development and regular updating of national action plans to implement the Beijing Platform for Action and reporting on their implementation to parliaments and international bodies; and

-- Cooperating with the mass media to mobilize public opinion on gender issues.

Panel Discussion on Women and Health

Dr. SANDRA DEAN-PATTERSON, Coordinator of Health Social Services, Sandilands Rehabilitation Centre, Ministry of Housing and Social Development of the Bahamas, said that violence against women and children were almost the norm where she came from. She wanted to address three aspects, namely, mental health, domestic violence, sexual abuse and female substance abusers. There was still the belief that women were the second sex and that men were the leaders. Given that distorted societal lens, health care policies had also been distorted. Too many women fell through the institutional cracks because the root causes of their problems were never addressed. While domestic violence and sexual abuse had been more exposed over the last 20 years, much more needed to be done.

With regard to substance abuse, she said that women admitted to male- oriented substance abuse programmes often did not complete those programmes. In her country, less than 10 per cent of women admitted to such programmes did not complete them. The double standard which enabled men to boast of their sexual exploits and still be capable of social acceptance, was the very standard that was a major deterrent to the successful treatment of the female substance abuser who had frequently bartered the only commodity she had to get by -- her body.

She said that it was crucial that substance abuse treatment programmes integrate new research on women's psychology and pay particular attention to the local social, cultural and religious systems affecting women's lives and psyches. Treatment programmes should begin with women's stories as a base from which to work and should take into consideration the ways in which women had experienced power. In addition, mental health and HIV health care providers had to come together to develop special programmes for women substance abusers who were also at particular risk of HIV infection, as they resorted to selling their bodies to sustain their habits.

Governments needed to invest in education, particularly on educating young children on what it meant to be male and female, she said. Systems needed to be put in place which did not re-victimize the victims of violence. A criminal justice system that did not allow the participation of victims fostered isolation and powerlessness. Also, the special needs of female substance abusers had to be recognized. In addition, gender specific HIV prevention campaigns had to be targeted at specific groups. Women's health

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was primarily influenced by the environment at large. There needed to be a firm partnership between non-governmental organizations, the health sector, education, religious institutions, and legal and law enforcement agencies, with training and sensitization as the main vehicles of ideological transformation. She suggested that non-governmental organizations work with the health sector in designing programmes for primary school children, exploring gender identities, new models of power and alternatives to violence as a way of resolving conflict.

Dr. MAHMOUD FATHALLA, Professor of Obstetrics and Gynaecology at Assiut University in Egypt, said there was more to women's health than reproductive health -- "a women is not womb, a women has a womb". The health needs of women could be broadly classified under four categories. First, women had specific health needs related to the sexual and reproductive function. Second, women had an elaborate reproductive system that was vulnerable to dysfunction or disease, even before it was put to function or after it was put out of function.

Third, he said, women were subject to the same diseases of the other body systems that could affect men. But the disease patterns often differ from those of men because of genetic constitution, hormonal environment or gender-evolved lifestyle behaviour. Diseases of other body systems or their treatments may interact with conditions of the reproductive system or function. Fourth, because women were women, they were subject to social diseases which impact on their physical, mental or social health. Examples included female genital mutilation, sexual abuse and domestic violence.

Health services for women should be seen as ends, not as means, he added. Often health systems were limited to addressing major health problems instead of preventive care. Education of girls, for example, was crucial to reducing pregnancy rates and nutrition was important for creating a healthy population. While the world needed to make basic health care accessible to women, there was more needed in health care systems. They needed to look at health care with a women's lens. The system needed to change from a "his system" to a "her system" -- they need to change from being hyper-medicalized and impersonalized to being more human and equitable.

The neglected tragedy of maternal deaths was one of the biggest concerns in the world today, he said. One woman dies every minute from birth-related complications. That was just the tip of the iceberg of human suffering. The international community needed to go beyond rhetoric and take more action. The problem of maternal deaths should be raised to the platform of human rights. Pregnancy was not a disease. Societies had an obligation to protect women's life and health when they become pregnant. Also, to make motherhood safe, obstetric care should be made accessible to all mothers. There was no alternative to that kind of care.

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Professor STEPHEN MATLIN, Director of the Human Resources Development Division of the Commonwealth Secretariat in London, said that the mainstreaming of gender into health services was not just about offering more women's services. There was a need to correct gender biases in the health field and that required fundamental changes in behaviour on everyone's part. There was a need for tools to insert gender into mainstream health practice. One of those tools was policy formulation. However, the existence of a strong statement on gender was not a guarantee that the policy would take effect. There was also the need to change attitudes and raise awareness. However, awareness was not a guarantee of better treatment and sensitivity. Countries needed to design health policies and programmes which required understanding by all actors involved, not just the health experts.

Another key tool for mainstreaming gender was the provision of accurate information for decision-making, he said. Programmes and services were usually assumed to be available and of good quality, but that was not always the case. It was vital to have information systems to analyse health systems to acquire good data. Mechanisms for determining gender and health priorities were often lacking -- relying on guesses instead of solid data. There was also a need for research on health problems being faced in a community.

The legislative framework should include pro-equality laws as well as the removal of existing discriminatory provisions, he added. Most of all, what was needed was political will. Success in implementing a gender perspective only came when leaders at the highest levels put their energies into change. It was also important to engage men in the process of gender mainstreaming. Men were part of the problem and their basic social ideas must be challenged.

Dr. PETER PIOT, Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS), said that he wanted to focus on violence against women and girls, and its impact on the spread of AIDS. Most countries had completely failed to address that issue. In many societies, the issue was considered a private matter and not to be made public, that was the major part of the problem. The scale of violence against women and girls was frightening, but so was the scale of HIV/AIDS among women. Of the 33 million people living with HIV or AIDS, 43 per cent were women or girls. Even the threat of violence could kill and cause AIDS, by killing the dialogue among partners about sex and life. Those at highest risk of HIV/AIDS were young girls. Over half of the new AIDS cases occurred in the under-25 age group. Girls became infected at a much younger age than boys, perhaps due to the fact that girls were more often subjected to violence than boys.

The international community might look on male violence against women as legally intolerable, but it was still considered an acceptable part of life in many societies, including by their victims, he continued. Violence against

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women was not just a cause of the AIDS epidemic, but it could also be a consequence of it. Of those whose infection status became known to others, many suffered direct violence at the hands of their husbands, family or community.

He said that to help reduce the impact of violence on AIDS, there needed to be a more effective global response. First, more political commitment at the highest level was needed to bring about the social and legal changes needed to better support women and girls. Secondly, only a dedicated, more inclusive approach involving broad partnerships with governments, local communities, and the media could help bring about such changes. Thirdly, there was a need to break the silence. The battle could not be won without openness about sexuality and AIDS. Fourthly, current resources for HIV prevention were grossly inadequate. Also, resources had to be used for approaches and interventions that worked. As part of the United Nations campaign to end violence against women, the voices of millions of vulnerable women had to be heard. Also, there was a need to explore more honestly what men's responsibilities should be with regard to curbing male violence towards women.

Question-and-Answer Period

Prof. MATTLIN, in response to a question on gender equality in health services, he said there was a need to keep policies for gender equality moving forward. Machineries and frameworks should be in place to keep the whole process moving forward. On training programmes in gender and health, he said the Commonwealth undertook a project to identify the 15 most important health issues in relation to gender. Those issues were used to create a curriculum guide to be used by health institutions around the world.

Dr. FATHALLA, in response to a question on indictors for women's health, said there were a number of indicators prepared by United Nations agencies. One was a series of indictors for safe motherhood. Another was an indicator of women's health. On medically assisted conception, he said that there was a psychological and social cost to those procedures as well as a financial cost and that should be taken into account. In response to a question on dedication of resources for health services, he said that it had been shown that more resources should be given to preventive services rather than to high-tech treatment of diseases.

Dr. DEAN-PATTERSON, in response to questions on sexual assault by men, said that sexual offenders in the Bahamas were now tried as criminals and sent to prison. In terms of counselling, it had been shown that counselling for adult sex offenders was not very productive. Counselling could make more of a difference on boys in their adolescence, because that was when they were developing their behaviour patterns.

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Dr. PIOT, in response to a question on HIV/AIDS, said that no health problem occurred in a social vacuum. The link between AIDS and poverty was very clear. It was poverty that drove women into sex work and to unprotected sex, which exposed them to infection. In poor countries treatment programmes were insufficiently funded, especially in those countries hit by the recent financial crisis. Literacy levels and education were also seen as deterrents to the spread of AIDS. In response to a question on preventing violence against women, he said it was important to work with leaders and opinion makers so that societal norms could be changed.

On a question regarding the link between HIV/AIDS and female genital mutilation, Dr. PIOT said that women who had experienced genital mutilation were more susceptible to HIV. However, there was very little documentation on that and other health problems arising from such practices. AIDS was just an additional argument for stopping female genital mutilation, but it was not the most important one.

Dr. PIOT, on the issue of quality of life indicators, said that there was a need to take a leap forward in the creation of such indicators. There had now been investments in qualitative studies to distil indicators which would be simple enough to use. Currently, there were no such indicators and an investment in their creation was needed.

Turning to creating greater awareness among men, he said that one had to start with changing norms, moving away from "machismo" attitudes. Focus had to be on young boys and men, and everyone that helped to create those norms, including the school system and the media, had to be involved. Also, there was a need to move from legal approaches to more community-based approaches.

Dr. PATTERSON said that women's mental health had only recently begun to be addressed. Women tended to manifest depression more readily than men, and it was more acceptable for women to do so. What was needed was to integrate mental health into primary health services to ensure that it was recognized and treatment for it was made available.

Dr. FATHALLA said that regarding mental health and hormones, women's mental health problems should not be blamed on their biology and hormones. Those problems were, for the most part, the outcome of the social problems they had and lived in.

In the area of research on male fertility regulation, he said that there were two problems in developing good methods for male fertility regulation. The first problem was biology, which contained two important issues. The first was that it was more difficult to control the process in men than in women. The second issue was the relationship with potency. The second problem in the development of methods was the perception by the pharmaceutical industry that men would not use methods of fertility regulation. The good

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news now was that on both accounts there was progress due to advances in cell biology. There had been a number of studies which showed that men would accept methods of male fertility regulation. In addition, a number of pharmaceutical companies were now investing in developing such methods.

Turning to family planning and safe abortions, he said that better family planning could be provided if it was provided in the context of a reproductive health approach. Regarding abortion, as agreed in Cairo and Beijing, every effort should be made to decrease the need for abortion. One available and underutilized way to do that was emergency contraception, which could be used by women if they had been exposed to unprotected intercourse. Unfortunately, it did not receive wide publicity and was not utilized in many countries.

Prof. MATLIN said that the protection of health service providers, especially in the area of abortion, would require zero tolerance of violence against them and rigorous implementation of legislation. On the issue of male fertility regulation, back in the 1980s when work had first begun on the issue, there had been two barriers to progress. One was the attitude of pharmaceutical companies and the other was the belief that even if such a pill existed, women would not trust a man who said that he was on the pill. Both of those attitudes were changing.

Prof. MATTLIN, in response to a question on poverty and ill health, said that poverty eradication was becoming an agenda item for a number of agencies. International financial institutions were starting to consider debt forgiveness, which would help many developing countries. It was also very important not to accept the argument that addressing women's issues had to wait for resources. Work on gender issues needed to start in order to improve economic prosperity.

Dr. FATHALLA, in response to a question on what was being done on preventing pregnancy for adolescent girls in Egypt, said that many of those pregnancies were due to early marriage. That could affect health as well as employment prospects later in life. To address that problem, there needed to be a minimum age for marriage as well as greater education of girls. Progress had been made in Egypt in that regard.

Dr. DEAN-PATTERSON, in response to questions on the need to bring women's issues to the heads of government, said that, if violence against women could be addressed on the highest political level, it would make a big difference. On the Bahamas crisis centres, the Ministry of Health provided the physical facilities for the centres and the Government allowed the centres to operate independently. That was a good plan for operation.

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Dr. PIOT, in response to a question on efforts to address HIV/AIDS, said a number of countries had made efforts to reduce the price of drugs to treat AIDS. There was also a need to rethink the care for mother and child with AIDS such as finding alternatives to breastfeeding. On programmes that targeted men, he said there had been some efforts to target men who had sex with men. That behaviour did affect women because those men usually had sex with women as well, and that could cause the spread of disease. There were also programmes that addressed men in the military. Those efforts attempted to change their attitudes and behaviours to have greater respect for women.

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