home > by publication type > transcripts > Focus on Women Policy Symposium: Session 1
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| Speakers: | Isobel Coleman, senior fellow, U.S. foreign policy, Council on Foreign Relations |
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| Nicholas D. Kristof, columnist, The New York Times | |
| Laurie A. Garrett, senior fellow, global health, Council on Foreign Relations |
November 30, 2004
Council on Foreign Relations
New York, N.Y.
NICHOLAS KRISTOF: We’d like to welcome you to this morning’s session. A couple of brief reminders about the Council rules. Normally this is a moment when we threaten everybody with a warning that it’s off the record, but in fact it’s on the record, and so you’re free to quote or misquote everybody as you choose. And also please do turn off your cell phones and other devices like that. I just did mine so I wouldn’t get buzzed up here.
The issue of— I’m Nicholas Kristof from The New York Times— and the issue of women in the Third World has been a special interest of mine since the time I was living in China. And my colleagues and I had all covered the [June 1989] Tiananmen Square massacre in which, we don’t know, but probably somewhere between 400 and 800 people died, and it, you know, captured the imagination of the entire world. And then, sometime a little bit later, I read that 700,000 women every year in China, year in, year out, end up being kidnapped and sold into marriage and different areas and sort of enslaved in some sense; and then later realized that 1.8 million baby girls go missing each year, some through selective infanticide, some through selective abortion using ultrasound; and that, all told, about 30 million females were missing in China. And kind of the scale of attention in the West to, you know, the political protestors who get attention and the much larger scale of rights abuses that affect typically peasant girls and peasant women that never get any attention seemed, you know, a reminder that this is a topic that deserves far, far more attention.
And the way that I’ve increasingly come to think of it, is that in the 19th century, the pre-eminent moral issue that the world confronted was that of slavery. In the 20th century, it was the various isms— totalitarianism and the struggle for liberty in the face of that. And in this coming century, I think the equivalent moral struggle that will dominate will be the effort to provide some kind of gender equity, particularly in the Third World, where it is so much a matter of life and death.
We have two people here who are very, very well-qualified to discuss this. They’ll each make some opening remarks, and then we’ll open out into a broader dialogue here. Isobel Coleman has an unusual background. She ran a health services company. She was a partner at McKinsey [& Company] and has now joined the Council as a senior fellow. She’s an expert on issues of women in development. She wrote an excellent piece in Foreign Affairs in, I believe, the May/June issue, which I highly recommend, about precisely these issues. And so, Isobel?
ISOBEL COLEMAN: Thank you. Thank you all so much for coming today, and thank you for your great opening remarks. I think you summed it up better than anyone can that the opportunity and the challenge in the 21st century is female empowerment in the developing world. I think it’s an incredibly important issue and one which has not gotten the attention that it deserves.
When I started focusing on development issues, with the goal of understanding how to make development more effective, over the last several years, I was quickly drawn to the issue of women in development. It really seemed like the low-hanging fruit. And the work of development economists like Amartya Sen and others have shown that women are truly critical to many different development objectives. Be it improving child nutrition or health or reducing fertility, or education, much of it comes back to the role of women in the community. And yet, while there’s an increasing awareness and recognition of that importance, there’s still a very big gap between policy rhetoric and the reality of policies that actually are targeted and directed towards women. And in trying to understand what is behind that gap, I think it comes down to a widely held misconception that focusing on women is somehow a Western concept driven by fairness and equity. Without a true understanding that in fact women are central to the solution of development— and in fact we will not get development in the way that we want it, both economic and political development, without focusing on women.
There are a couple of things that I want to focus on today, just briefly touch upon. The first is girls’ literacy. There’s no silver bullet in development, but I think what comes closest to it may be girls’ education. Larry Summers [president of Harvard University and former U.S. Treasury secretary] has pointed out to us that investing in girls’ education may be the highest return that we can make in the developing world, and we know now, we know very clearly and strongly, the very strong linkage between girls’ literacy and many other development objectives. It’s well known that educated women tend to have fewer children. For every three years of education that you provide a woman, it tends to reduce their own individual birth rate by one child. Educated women also provide better nutrition and health and education to their families. And they experience lower child mortality and generate more income than women with little or no schooling. This creates a virtuous cycle for the whole community. And yet today, two-thirds of the illiterate people in this world are women. Educating girls actually returns higher yields in educating boys, and we have evidence to show that, and it’s because primary education has higher yields than secondary education, and women, girls, tend to be concentrated on the lower ladders of the educational system. And children benefit more when their mothers are educated than they do when their fathers are educated.
So when you increase the mother’s level of education, the children— their nutrition and health tend to go up, and they tend to stay in school longer and get more schooling than when you educate the fathers. And educating women also increases their productivity, and this has profound implications, I think, over the next century, in particular for agriculture, which is increasingly becoming a female endeavor. As men leave the villages and move to the cities, the farms are left to women, and there have been several studies that now show that when you provide women with basic literacy it can have a more profound impact on agricultural productivity than increasing fertilizer usage or increasing plot size. And in our world of constrained resources today, this is something we should all take note of.
The second area I want to touch upon briefly is women’s control over economic resources. When you give women access to income, it benefits the whole community at large, since women have been shown to invest more in the family than men do. And again, there’s studies from a variety of countries, as varied as Bangladesh, Brazil and the United Kingdom, that show that women tend to invest more in the family in terms of children’s education and health and nutrition when they have marginal income than when men do. Increases in female income improve child nutrition 20 times more than increases in male income. And female borrowing— so when women are actually borrowing in small amounts or large amounts— it also improves child health and nutrition more than when men are borrowing. And this helps explain why micro-finance is such a powerful tool today in development, both economic and social development, in the world. I’m not going to spend a lot of time talking about micro-finance now because I know it will be the focus of one of our later sessions.
And the third and last area I want to touch upon is political voice. We know that giving women a say in the political system is good for democracy, especially in many of these developing countries, where women make up the majority of the population. But what’s now being understood is that they’re also a force for moderation and moderating extremism. And we also know that when women do have power, they use it differently than men. Women around the world, from Latin America to South Asia to Africa, are often at the forefront of community mobilization levels at the most basic grassroots level. You see women taking up civic issues, be it education or health, but quickly translating that into political issues and mobilizing the community on political topics.
I just want to talk briefly about the use of quotas, which is a very interesting development in some of the most traditional societies around the world, from Morocco to Afghanistan. And you see women taking advantage of these quotas to gain a critical mass within local governments. And the country that may be furthest along in this experiment is India, which has reserved a third of its local seats, the local panchayat, for women, and that’s been going on for the past seven years now. And you see quite a profound change in the way that resources are allocated at the local level. So putting women into positions of leadership at the most basic local level changes the way that resources are allocated. It’s not to say that women’s priorities are better than men’s, it’s just that they’re different; and given that they make up half or more of the population, it benefits the whole community when their interests are represented.
And lastly, you see some visionary male leaders around the world today recognizing and harnessing the political power of women. And I will note the recent election in Afghanistan, where [President] Hamid Karzai campaigned directly for the women’s vote in Afghanistan. It’s quite remarkable, this country that we’ve all read about and the role of women in that country, to see the leading presidential candidate out stumping on women’s issues and trying to get the women out to vote. And it was very effective for him, because he recognized that in those areas where he could get women to the polls, they voted disproportionately for him, and because they really believed in his vision of moderation and tolerance and development for that country. And so you can see the power— the political power of women in places like Afghanistan today when they are allowed to mobilize and go to the polls and have those opportunities. But those opportunities do come back to what I started talking about, which is literacy and economic opportunities, and it’s all interrelated. I’m going to stop there— we have lots to talk about— and turn it over to Laurie.
KRISTOF: Laurie Garrett is, I believe, the only journalist to have amassed the three P’s of prizes— a Pulitzer, two Polks and a Peabody. [Laughter] And that was while working for Newsday. But maybe the more important journalistic triumph that I think Laurie is associated with has to do with one of journalism’s failings, and that traditionally has been public health.
Over the last couple of decades, journalism has covered a lot of things better than we used to. Public health is still one of the areas that we just don’t get right, especially around the world. And Laurie was a pioneer in showing how journalists could cover public health issues around the world in a way that was compelling and important. And she has really become a model for journalism in doing that. And alas for journalism, fortunately for the Council, she has left Newsday and is now here at the Council as a senior fellow. So, Laurie?
LAURIE GARRETT: Thank you, Nick. Many, many years ago, when I was first starting this journey of thinking about public health in the world and trying to understand how to look at it as a journalist, I spent some time— well, I’ve spent a lot of time over the years— but in this particular trip in sub-Saharan Africa, and I was in Zimbabwe when people thought of Zimbabwe as the great success story. Hard to believe there was such a time, but there was. And I was trying to understand why children were still dying in disproportionate numbers in Africa, and had been shocked to have a child die in my arms of measles, a disease that we completely treat in a nonchalant manner in the Northern Hemisphere. So I spent time in the village trying to understand why were children dying of measles. And I discovered that the dynamic is as follows.
First of all, agriculture is women’s work, not men’s. And it’s traditionally so in much of Africa. The men are in the urban areas. They come back to the village once or twice a year to re-impregnate their wives and collect whatever money she’s managed to amass from selling the crops and take it back with them. And that’s about the total relationship. In the city they have a whole other life, family, a whole different life. But when a child becomes ill, particularly if it’s one of the male children, the wife must— she cannot go directly to get healthcare; she must have permission from the husband first. And so, even though this child’s life hangs in the balance with seconds ticking away, she would have to walk 10 or 15 kilometers to a bus station, wait for several hours for the bus, take the child to the capital city or whatever is the city that her husband is in, find him, and gain his permission to take the child for healthcare. The result? Most of these children die before the woman can get permission to receive healthcare for the child.
Well, I happen to believe in empirically based foreign policy decision-making, and so I’m going to run some numbers by you and let the numbers tell the story for themselves. Right now in Kenya, 1,000 out of every 100,000 women die in childbirth annually, versus 8 out of 100,000 in Japan. Overall in sub-Saharan Africa, the maternal mortality rate is 920 per 100,000. The infant mortality rate differential is equally eye-opening. Sub-Saharan Africa, it’s 172 deaths of infants per 1,000 live births. Just let that sink in. Whereas here in the United States, it’s about eight. For under-five mortality, the worst rate is seen in some of the rural areas of India where 158 children out of every 1,000 die before achieving the age of five. These tell huge numbers.
The other big demographic number to consider is that actually in the developing world, healthcare is a cash-only business. Whatever you hear about the existence of a national health system, forget about it. In fact, in most developing countries, about 89 percent of all healthcare is out-of-pocket cost, which, if you have a society in which women do not have cash, means that, frankly, you cannot get healthcare without the involvement of the husband or a male family member. In the northern hemisphere, we’re seeing a shift— a huge demographic shift— in the age balance of the planet, as we are aging at a dramatic rate, what’s called the age wave. And the key implication of the age wave, where 60 countries will have more than 2 million of their population over 65 at any given moment, is that it puts a burden on women. And we’re going to see a huge shift in the fiscal burden, the caretaking burden of women in the wealthier countries with this age wave, because who is it that lives to be 100? Overwhelmingly, it’s females. What are they left with as resources in their old age, particularly if their husband passed away 30 or 40 years before them and they did not have a lucrative career on which now they can live in retirement?
While that is happening here, what we see in sub-Saharan Africa, and increasingly in parts of Asia, is a shift in the nature of disease and caretaking for disease, so that in much of sub-Saharan Africa now HIV is called “grandmother’s disease”--the reason being that the parents have both died of AIDS and these elderly women are now left in their retirement to raise dozens, in some cases, of orphans.
A recent survey in the Rakai District of Uganda, where about 20 percent of the adult population is HIV-positive— contrary, by the way, to our administration’s constant insistence that Uganda is a miracle story, that through abstinence and faith-based marriage initiatives [it] has lowered its infection rate to 5 or 6 percent; indeed, it’s more like 20 to 25 percent in the hard-hit parts of Uganda. And there we see that about 15 percent of all children are now orphans, the majority of whom are being raised by their grandmothers. So that is a huge shift demographically already live and in action. And one big piece of that is remembering that agriculture is female work. If you’re talking about an 81-year-old grandmother trying to do agriculture and raise 10 grandchildren, and teach the girls how to do the agricultural work, you can begin to understand why we see increasing famine and lower agricultural productivity all across the hard-hit HIV belt of sub-Saharan Africa.
Tomorrow is World AIDS Day, so I’m going to focus a little bit on HIV. One of the big things you’re going to be hearing and you’re going to read in all the newspapers tomorrow is that the United Nations AIDS Program has released a new annual report that says that in sub-Saharan Africa now, 60 percent— 6-0— of all HIV is in women. Increasingly, HIV is becoming a women’s disease. It’s quite a turnaround when you think about 20 years ago here; we thought of HIV as a gay man’s disease. And increasingly it is shifting downward in age in the females and upward in age in the males. A few things are germane when you think about that. Even with this massive pandemic in the background, household surveys across southern Uganda, which has the oldest AIDS epidemic at this point— in some areas into their fourth generation of this pandemic— still today, when you survey women in the households and ask them what’s your No. 1 health problem, 25 percent say just generally the background of illness, all illnesses combined. But by far the biggest problem, 35 percent, is we don’t have any money. The lack of cash in female hands limits all possibilities of both dealing with the health of yourself and your children, and countering the tremendous impact that something like HIV may have on your household.
The other issue is the level of sexual activity and some of the changes that we’re seeing across sub-Saharan Africa in sexual activity. If you compare the activities of the males and the activities of the females, it’s a very, very striking differential. For example, one large survey asked men and women, “Have you had more than one partner in the last 12 months?” Men, depending on where in Africa you asked the question, anywhere between 35 [percent] to 40 percent say, “Yes, I’ve had more than one sexual partner in the last 12 months,” whereas rarely do you see more than 8 percent of women saying yes. So we know we’re getting the HIV and bringing it into the household, and we also know that fewer and fewer of the women are in a position to protect themselves.
A national youth survey in South Africa just published found that 77 percent of young South African women have no idea how HIV is spread still today, the knowledge level being so low. Nearly one in four of South African women aged 20 to 24 are HIV-positive, while only 14 percent of their peer males are. This is because they’re having sex with older men. Older men are actively seeking them out as sex partners for a number of reasons, including a notion that they’re protecting themselves by having sex with a younger woman who may have had less activity and therefore be less likely to be infected. Another recent report released found that 41 percent of all HIV infections were in women as recently as 1997. Well, now it’s up to 60 percent in sub-Saharan Africa, largely due to this “sugar daddy” syndrome; younger girls wanting to— being in dire economic circumstances, and seeking out older men that may help them out.
In Cambodia and Vietnam, just to make sure you don’t see this only as an African phenomenon, a survey of 15- to 24-year-old girls found that the majority thought you could get HIV from a mosquito bite and only 35 percent understood that someone who looks healthy as a sex partner might actually be an HIV carrier.
Now, the other issue that ties in with this is violence against women. A survey, again in South Africa, just completed, found that women who report recently being a victim of violence from their sex partner were 48 percent more likely to be HIV-positive. And we are seeing a rapid increase in rape rates, particularly as many men are of the belief that if they have sex with a virgin it takes their HIV away, and so they’re seeking ever younger sex partners, often actually in the form of rape.
Now the other issue is that most of the women I’ve interviewed in Africa who are HIV-positive were wives— monogamous wives. HIV came into the household because of their husbands’ sexual activity. In most cases they have no possibility to escape that scenario. And they cannot ask their husbands to use a condom; that was sure to get them a beating at the very least. And the assumption is if they even understand what a condom is, they must be a prostitute, they must be cheating on me, I must beat my wife, maybe I will throw her out of the home penniless and reject the children that she bore me. Right now in Swaziland, 40 percent of adults are HIV-positive. The majority of those females who are HIV-positive are monogamous married women, which to me really forces us to think about just how humane, how rational is it to argue that the key elements of an HIV campaign are abstinence and faithfulness in marriage? These women are faithful in their marriages, and they have no possibility of being abstinent as they cannot dictate the terms of sexuality with their spouse. And only 11 percent of women in Zambia, where the HIV rate is astronomical, said that they felt they could ever raise the subject of the use of a condom with their husbands.
Later today in another session, fortunately, we’ll have some discussion of one possible alternative, the use of microbicides, but that is not an alternative that is readily available at this time. A new survey in Zambia finds that 70 percent of the HIV population in Zambia now is female. And yet— and here comes the next stage of the discrimination— and yet 80 percent of all the antiretroviral drugs available in Zambia are going to men. And this is the other trend we’re beginning to see all across Asia and sub-Saharan Africa, as the World Health Organization and a host of nongovernmental organizations and our government try to roll out antiretroviral therapy: women aren’t getting it; it goes to the men. And even if it is given to many women, they will pass their drugs to their firstborn son rather than take the drugs for themselves, and then they will end up in their dying days being the caretakers for a family that is in dire circumstances.
Now lest you think this is just an overseas phenomenon, I just want to point out, and then leave lots of time for question and answers for all of you, half, it is estimated half of the HIV-positive women in this country who should be on antiretrovirals do not have access to antiretrovirals at this time— half. So we are not just talking about a phenomenon that’s over there; we’re talking about a phenomenon that’s right here as well, and one that we don’t fully understand here in the United States, where we obviously have a far higher degree of female empowerment.
Finally, it is a general conclusion from most of the agencies directly trying to tackle the HIV paradigm that there’s really no way to, in a lasting sense, tackle HIV without at the same time tackling female empowerment. The two are going hand in hand, and it’s inescapable. It has been inescapable for a long time, but it is now being recognized at the highest level.
KRISTOF: Thank you. Let me grease the skids a little bit by asking a couple of questions. And, Isobel, let me ask a bit of a skeptical question. I think you alluded to the notion that one of the arguments for female empowerment in the developing world is precisely the notion that women, once they are in decision-making capacities, will rule in a different way and perhaps a more enlightened way. And I just wonder how much basis there is to think that there really will be better rule there. I mean, if one looks at [Pakistani Prime Minister] Benazir Bhutto, for example, then I would have thought that [current Pakistani] President [Pervez] Musharraf probably rules in a way that is more beneficial to the women of Pakistan than Benazir did. And one looks at Mrs. [Indira]Gandhi in India or Mrs. [Chandrika] Bandaranaike in Sri [Lanka] that it doesn’t seem to me that, for whatever reason, the women who have actually managed to claw their way to power in these countries have been very reassuring from that point of view. Is—
COLEMAN: I would tend to agree with you, that when you look at women in the highest levels of leadership, they have clawed their way to power and they’ve done it by playing the game, and playing the game sometimes even in a worse way than the men have played it.
What I was referring to was something actually quite different, which is giving women grassroots power, and I think there we do have some evidence not that women rule better than men, but that they do rule differently. And the place where we see the greatest evidence is in India, and this panchayat experiment has been going on for, as I said, six or seven years now. And you see women have been granted not only a third of the seats in the panchayat, the local council, but also a third of the leadership positions of all the different villages must rotate to a woman. And when you see both the critical mass of women at the grassroots level and the women at the leadership level on this local council, you do see different allocation decisions, particularly on the budget. I mean, that’s what we’re talking about. They have local funds to allocate, and the women allocate it differently than men. They have different needs because they do different jobs in the community.
So you see that the fetching of water is women’s work. And so suddenly when the women are in power, irrigation and clean water gets much higher priority than it did before when the men were in power. And this isn’t to say that the things that the men focused on, although I don’t think— is Mary Anne Weaver here? She’s a fellow at the Council this year, and she wrote a terrific piece in The New Yorker a couple years ago that talked about how, when the men were in power, they spent a lot of time paving over the roads in front of each other’s houses and it didn’t actually benefit the community that much, and when the women took over, they started really focusing on clean water and education. And they’re just— it’s just different priorities, and arguably priorities that have in many of these communities been neglected and benefit— have a communal benefit, because of the long-term impact on the next generation.
KRISTOF: Thank you. And Laurie, Isobel alluded to the question of kind of— the critique that is periodically raised and kind of cultural superiority, that we’re imposing values. And how do you address— isn’t there actually something to that, that one of the obstacles that we’re talking about is not just kind of local repression, but is in fact local culture? And for example, the idea in Zimbabwe— when you began— that women have to consult their husbands before taking a sick baby to the doctor; I mean, that’s ludicrous and scandalous, but it does reflect local values. Female genital mutilation as well— you know, it’s a horrific problem, but it is— you know, if you— obviously the local societies— I mean, they think this is an important part of their local society. How does one— how do we, coming from New York, how do we address these kinds of issues without inflaming the sensitivities about, you know, imposing our values and our ideas and our traditions on different people?
GARRETT: That’s a really good question because I think it’s a common mistake made by a lot of NGOs, nongovernmental organizations, a lot of faith-based organizations, and some government initiatives. There’s this sort of defining empowerment in American terms or in European terms, and therefore thinking that, you know, the most oppressed woman is perhaps a woman under Islam or that the standards of defining empowerment will be equivalent to those things that we’ve used as standards in the United States. And I think that’s a huge mistake.
When we talk about empowerment, let’s just start at bottom baseline. Who gets to say what happens in the bedroom? Does a woman have any control over her sexuality whatsoever? It is not a coincidence that HIV is at the highest levels in the countries where women have the least say-so over their own sexuality. It’s in rural India, it’s in sub-Saharan Africa, and increasingly, you see a sexual transmission in parts of Asia where women are really lacking in that power. So we’re not talking about power necessarily that immediately translates into you’re sitting in government or you’re the chairman of the board of some local company.
The other thing is, Isobel talks a lot about the importance of empowerment in terms of, you know, some local governance. And one of the things that has been known for a long time in public health circles but rarely talked about outside those circles is that— and UNICEF [United Nations Children’s Fund] in particular has pioneered this understanding— is that you will get higher child health indicators across the board where women are better educated. So if you educate a woman, even a little bit, a tiny bit of knowledge translates into a higher vaccination rate for children, a higher likelihood that she will take those children for regular check-ups of some kind, a higher likelihood that if she receives bed nets to protect her children from mosquitoes that would transmit malaria or dengue fever, she will know how to use them and they will be put to use, and a higher probability that she will negotiate successfully with her husband over how household resources are spent, so that at least some of the spending is directed to the health of the children.
So the data is clear, the data is very clear, and I think where NGOs screw up a lot, when I see it on the ground, is when women who have grown up, as I have, with a swagger and a belief that if I just struggle hard and I’m smart, I can probably get what my brothers got and— though that wasn’t really true [laughter], my brother got put through Stanford, but I had to go to a public school. [Laughter] No. But nevertheless, you know, we had that sense. And I see, when I travel around the world, I can spot an American woman from a hundred yards just by the way she walks. She walks straight forward. She makes eye contact. She carries her shoulders back, and she has no sense of servility or any notion of dominance. And we have to figure out a way that we interact with women who have no possibility of having that same carriage in life, no possibility whatsoever, and yet can interact with us without thinking that we’re aliens from another planet or in fact appalling, in fact disgusting, because of the way we carry ourselves.
COLEMAN: Can I comment?
KRISTOF: Yeah. And can I just frame that a little differently for you, too?
COLEMAN: Yeah. Yeah.
KRISTOF: That in Afghanistan in particular, where there are so many NGOs that have rushed to Afghanistan to try to help the lot of Afghan women, and frankly I think they have a pretty mixed record, that a lot of them haven’t been very successful— they’ve, you know, antagonized people for— one NGO gave away soap to Afghan women and thought, you know, what could be a better idea that soap? And it turned out that in Pashtun society that soap is basically used after sex, and so they were suggesting that all these women were promiscuous and caused a near riot. And you know, these poor NGO guys were just— they hadn’t intended any kind offense, obviously. But given, you know, the problems in Afghanistan, what— you know, what kind of interventions by NGOs actually are going to be the most effective? Is it literacy, for example, do you think? Or where do we increase the odds of success?
COLEMAN: Education, education, education. It’s— to me, it is so absolutely clear and compelling, and yet— you know, there are a lot of well-intentioned people and ideas, but much of what is trying to be achieved in Afghanistan and in many of these countries really has much limited chance of success without raising the literacy rates of women. And if you could do one and only one thing, it’s raising literacy rates. And I think Laurie once said to me to— what would be the most effective use for some of the public health money? Girls’ education. I mean, it’s— I think it’s— there’s such a spillover and positive spillover benefit from educating girls, in so many different ways, whether it’s the economic benefits, the civil society benefits, the political awareness, everything that happens, and the impact on the next generation. And the reality today, unfortunately, is that the many, many millions and millions of young women in Afghanistan today don’t have that much of a chance of that much of a better life, but their children do, if they can get some education and if they can impart that education to their children.
KRISTOF: Laurie, would you agree? If you inherit a big chunk of money from some rich uncle, and you can dedicate that, where are you going to get the most bang for your buck? Would it be education? Would it be maternal mortality? What decides what we do—
GARRETT: Well, there’s a marvelous study done by the University of Antwerp, by a wonderful scientist, Bouve, where she tried to understand why it is that HIV has stayed at very low rates in West Africa and steadily skyrocketed in the east and the south. And right now Nigeria is the only country in West Africa that’s tipping over the 5 percent prevalence level, while all over in the east and the south, we have countries with in excess of 30 percent adult prevalence of HIV.
And after she scored for every imaginable factor in their study, only one thing stood out, and it was that West African women had a tradition, going back pre-colonialist, that the sort of small shopkeepers, the street vendors are women. And they actually control the business themselves, so that they keep the cash, whereas in the east and the south, traditionally, women really didn’t have access to cash. It was a rural economy, a lot of bartering, a lot of— or such modest levels of cash— you know, however much you could get for a few bananas— that it wasn’t enough that a woman could build a life.
So what that meant is that a woman can’t walk out of a marriage, no matter how dangerous it might be. I sat in a room once with about a hundred women in Kampala, every one of whom had gotten HIV from her husband and every one of whom had already buried that husband and now was struggling with the disease themselves and perhaps in their children as well. And every one of them said, “I knew he was infected. I knew he was cheating on me. I knew he had, you know, Susie and Mary and Sally and blah-blah-blah-blah, and I knew that that Susie girl was up to no good,” and on and on. But there was nothing they could do. It was just Russian roulette waiting for that moment.
So I guess I would say yes, education; but I would also say these microeconomic efforts, whatever they may be, that can give women some cash, even modest levels of cash that can allow themselves to extricate themselves from dangerous marriages and dangerous situations that literally now with HIV mean Russian roulette, can save millions of lives.
KRISTOF: One last question and then I’ll turn it over. And it’s kind of a follow-up on that. I mean, isn’t it true that fundamentally those societies that have managed to make real, lasting improvements in gender equality, in healthcare for girls and women, in education, have basically achieved that through economic development, and that it’s been very hard to improve the lot of girls or women in these societies without having the broader—
GARRETT: Not true. Not true. I disagree. One of the highest life expectancies, depending on whose database you look at, higher than ours, better infant mortality markers than ours, better child mortality markers than the wealthiest nation in the world, the United States, is Costa Rica. Costa Rica’s GDP [gross domestic product] is about 10 percent per capita of ours. Their health spending is about 1 percent of ours. And yet they do better. And all their child health markers and all their women’s health markers are better than ours. Why? Because they spend correctly and they spend with public health as their primary direction of spending, and they divert most of their resources to dealing with children’s health and the health of pregnant women, ante-natal health as well, while we divert, you know, more than 30 percent of all our health dollars are spent on the last two weeks of life. So we’re spending heavily on people who are over 65, over 70 years of age, while we have one out of five children in America with no health insurance and while we have more and more women in America going into labor having not had any pre-natal work, having not had any OB-GYN work, and not even fully understanding their own pregnancy and their own health because of lack of appropriate education. So it’s not necessarily the case at all that wealth brings health or vice-versa.
COLEMAN: Also, I think you can turn it around and look at the experience of the East Asian economies. And their gender gaps were the same, measured on girls’ illiteracy, infant mortality, girls’ nutrition, all sorts of things, as the Middle East and parts of South Asia in 1945. And they made such aggressive attempts to close those gender gaps that many economists today think it was a very big contributing factor to their economic growth.
And in fact, when you look at the difference in taking advantage of the opening economies the way that China and India have reacted, China’s been able to capitalize on it better than India, and again, many economists attribute it to the fact that the gender gaps in China are smaller than the gender gaps in India. They just have a much better female human capital. And I know that you know from your experience there that women are a huge part of China’s economic miracle and have been held back in India because of their lack of education and other opportunities.
And just one last thing I want to say. Your question about culture— I think you’re absolutely right, so much of this does boil down to culture. But culture is not unchangeable. It’s not immutable. And if you look at China a hundred years ago, it was unthinkable for a well-to-do family not to bind the feet of their daughters, and I think a hundred years from now many parts of the world will look back on the way that women were treated with the same sort of amazement, that “We used to bind their feet?”
And that change, though, it wasn’t the United States coming in and telling the Chinese, “You’re not going to bind the girls’ feet,” but within each of these cultures there are advocates and spokespeople from those cultures saying, “It’s wrong,” female genital mutilation, whatever the topic is, it’s wrong. And there are religious leaders who need to be harnessed, tribal leaders, to change that culture. And only when that happens will we have real progress and movement.
KRISTOF: Now we’d like to turn it over to you. Please identify yourself and do stand up when you ask a question. Who wants to break the ice? Yes?
QUESTIONER: Hi. I’m Cynthia Lloyd. I’m—
KRISTOF: There’s a microphone coming for you.
QUESTIONER: I’m Cynthia Lloyd. I’m at the Population Council, and I’m also currently chairing a panel for the National Academy of Sciences, which will be titled, “Growing Up Global,” which will be released on December 14th. And I want to follow up on what Isobel was saying about education, education, education. I think one of things we’re learning is that in fact there have been incredible strides. The growth rate in primary schooling around the—
KRISTOF: Please make sure you have a question mark at the end of [laughter]--
QUESTIONER: --OK— is very dramatic. But I think what we’re also learning— and I just wanted to throw this back at you— is that when we talk education, education, I think maybe we should go a little bit beyond the focus on universal schooling and begin to focus on what goes on inside the schools and what the kids are learning. So I just want to get your reaction.
COLEMAN: Well, I think that’s a very good point. This focus on education is not new. I think we’ve known for several decades now that education is really important. What is new is the understanding that we’ve gained from the last several decades of failure. Because we’ve gone and we’ve built schools in many of these societies and said we want the girls to come. And guess what? The parents haven’t sent them. And now we— and so we go back and we say why haven’t you sent your girls? Well, you built the school over there and we’re over here, and frankly, we’re not going to let our girls walk three or four miles; we’re not going to let them walk more than two miles. Oh, we should have figured that out before we built the school four or five miles away. So we build the school nearby, the girls still don’t come. Why not? Well, there are no latrines. And guess what? You know, we’re not going to have our girls go to school if there’s no facility for them to go to the bathroom. It’s too dangerous for them to go out in the fields. And it’s— you know, we get back to culture. You know, there’s a— the boys can do it, but the girls can’t. Oh, OK. So now we’ll build latrines. Still the girls don’t come. Why? Because now you want the girls to go to school during hours when they have to be home doing the chores? And you know what, we live on a farm; if the girls aren’t doing the chores, nobody eats, nobody gets water. Oh, OK. So now we’ll adjust the hours of the school and make it so that the girls can do their chores and go to school. They still don’t come. Why? Oh, because we have to pay for school uniforms? In fact, to your point about healthcare, education is still not free in many of these countries.
OK, now we check back. Guess what? All the girls go to school in some of the most traditional societies. And you’ve seen when you get it right, and when you work with the community, and you work with the village leaders to get it right, you work with the mothers, the fathers, the grandmothers to make sure you’re getting it right, the girls go to school. Now we have to start focusing about what’s being taught and what goes on within the schools, and that’s the next big challenge, and that’s applicable for girls and boys. But the challenge of getting the girls into school, we know what works. In fact, one of my colleagues here at the Council, Gene Sperling, did a terrific report on girls education>. We know what works. Now it’s just a question of implementing it.
GARRETT: I would just add that in terms of health, I mean, the kinds of things we’re talking about in the developing countries, I don’t really think we’re all the way up to dealing with sophisticated content here. I mean, if we could just have it that every female in the world has the equivalent of a third-grade American education and do basic arithmetic, a little multiplication and read and write, we’d be way ahead of where we are right now.
KRISTOF: Yes?
QUESTIONER: Bettye Martin-Musham from Gear International. We have a crisis in this country with nursing faculty, nursing healthcare providers. How do you think we’re ever going to get people to understand that teachers, nurses have to be paid? How do we have an impact and get some kind of resolution to what we need and how we’re going to pay for it?
GARRETT: It’s a really important question. We have a global nursing crisis right now. In fact, you know, [former third-party presidential candidate] Ross Perot used to talk about “that big sucking sound,” and he was referring to something in Mexico— I can’t remember what it was. [Laughter] But anyway, really the big life killer, life-threatening sucking sound is all the nursing skills of the third world being sucked into the first world because we treat nurses so poorly in this country, and in Europe, and so underpay and undervalue the labor. And we’re aging as societies, so that the amount of nursing care we need is increasing at a dramatic level, that we’re depleting the nursing forces of the poor countries. And in fact, right now, if you were in Botswana, you would hear from the Botswanans that they’re losing nurses as fast as they can train them, because they’re getting offered a higher salary in South Africa because all the South African nurses are being brought to the U.K. And in the French-speaking parts of Africa we see the same thing, with those nurses ending up in Paris.
I was in the Bahamas looking at their fight against HIV; they have the second-highest rate in the Caribbean. And they have the largest nursing school in the Caribbean; they graduate what used to be the entire nursing force of the Caribbean. But now, last year, more than 90 percent of the nurses graduated from the Bahamas ended up practicing in Texas and the southern parts of the United States. So we do have a crisis. It’s a very serious one. We’re never going to be able to address HIV, malaria, tuberculosis, and all the growing emerging disease threats unless we can come up with some solutions.
And without, you know, stealing their thunder, the Rockefeller Foundation just released a report on the human resources crisis in healthcare just this week, and I strongly suggest you take a look at it. Lincoln Chen was the primary author on that report.
KRISTOF: Yes?
QUESTIONER: Vincent McGee. I’m on the board of PATH [Program for Appropriate Technology in Health], which works on global health issues in many of the areas that have been discussed, but we don’t do very much work in Cuba. And I wonder if Laurie or Isobel could comment on positive lessons and negative lessons from Cuba, particularly relating to education of young women and AIDS prevention?
GARRETT: Cuba’s a complicated story because HIV originally came into Cuba via troops that had been in Angola in the 1970s, and was initially contained through quarantine, a mandatory quarantine; the only country in the world that had mandatory identification and quarantine of all HIV-positive citizens, and they hailed it as a success. It may have been for the first wave of these sort of soldier-based; but now, when in the mid-’90s, Cuba’s economy really started to unravel, you saw an influx of particularly European tourists and a rise in prostitution in Cuba. And now you see a more generalized HIV problem there that cannot be tackled with this quarantine approach.
On the other hand, Cuba does have 100 percent literacy, male and female. They do have a very strong public education program and an extraordinary public health program. They are— I think at this moment they’re the biggest exporter of physicians and nurses to the rest of Latin America. They have physicians practicing all over rural Africa, often in areas where the only other people out there may be Catholic missionaries. And they have their own antiretroviral production program. They’re trying to make their own vaccines for a host of different diseases. But you know, with all of that they certainly have not created a disease-free zone, nor a really genuinely female empowerment zone. [Isobel,] you want to talk about that side of it?
COLEMAN: I don’t know so much about Cuba, so leave it at that.
KRISTOF: Kati? There’s a microphone coming.
QUESTIONER: Kati Marton, the chair of the International Women’s Health Coalition. First of all, Isobel and Laurie, thank you for this really breathtaking but rather depressing account. I wonder if either of you could comment on the impact that global fundamentalism is having on women’s health and women’s status in general? Thank you.
COLEMAN: Well, I— first, I just want to comment on your comment that it’s depressing. And I hope it’s not depressing, because I feel that, in many ways, we stand on the cusp of something incredibly exciting and hugely positive, which is the empowerment of women in this century. I think it will take much of this century, but I think there’s an opportunity to change the lives of women in much of the world that has not happened in hundreds and hundreds of years in development in the rest of the world. And the reason I think that we stand on that cusp today is because there is a recognition, an increasing recognition, that countries can’t get to where they want to be economically without bringing women along, without bringing those poor and repressed women in many of the villages, without bringing them into the global economy and into the civil society.
And I think this comes to your question about fundamentalism, because in many parts of the world there are those who don’t share that vision and don’t want that vision. And they have a very different vision for women, which is to keep them very much sequestered in the home. And I think those countries which can’t make the transition to providing greater opportunities, economic and political opportunities for women, are going to fall further and further behind. And it’s a vicious cycle because I think the fundamentalists feed off of it; they’re both creating it and feeding off of it.
And I think that it’s so linked together. The idea that women cannot play a public role, be it a public role in the family, have a role in family, at the most micro level, at the family level, have a role in decision-making— I mean, the most extreme example of this clearly was the Taliban in Afghanistan. It was a fundamentalism that most devout Muslims would look at and say was horrific. It had gone horribly awry— to somehow interpret the Koran to say that women couldn’t even go to school. But there are places around the world where there’s an overlap of religion and culture, religion reinforcing cultural traditions, which is what you had in Afghanistan. And that is preventing women from getting education, from having access— to leave the home, to access healthcare and to really be productive citizens of their community. And I think you’re going to find that those countries, those villages, those communities are going to fall further and further behind.
And we see fundamentalism— we see it all over the world. There’s fundamentalism in this country, too. And I think that it’s a— I think it— what you see, though, with some of the most extreme fundamentalism overseas, as demonstrated by the Taliban, is hugely disastrous, not just for women, but for the whole country.
GARRETT: I would just add a couple quick things. The power of the voice of imams over the lives and behavior of women and children is profound. And we can see this in terms of health right now, when first a few imams in India began telling their followers that the Westerners had put sterilizing agents in polio vaccine, and you saw a sudden plummeting in the rate of polio vaccination just as we were on the edge of completely eradicating the disease from the planet. That was followed by imams in northern Nigeria saying that HIV had been put in polio vaccine in order to kill the children of Nigeria— the Moslem children of Nigeria. And as a result, we now have 12 countries with out-of-control polio, and it’s really reversed the course of what had been a planned eradication, to be achieved by 2005.
The other side of that, though, is what— and I guess I want to echo something that Isobel said about— yeah, all this sounds depressing, but let me try to give you a little positive spin. In this country, we hear a lot of rhetoric about Uganda and its, you know, historic achievements with HIV. And I alluded in my earlier remarks that I don’t believe the data sets that often get thrown out here about Uganda allegedly driving their HIV rates from something like 30 percent down to 5 [percent]. That’s simply not true. But what I have seen on the ground in those places where the rates have come down, such as the capital city of Kampala, is not so much the— an abstinence campaign, though there’s that message out there; not so much a big success in the faithfulness in marriage campaign, as we often hear here from our Christian fundamentalists in terms of the, you know, rhetorical support for efforts in Uganda; but rather that we are beginning to see female empowerment.
And it’s pretty radical. I mean, I’m struck by it in Kampala. When I was first in Kampala just after the [Ugandan military dictator] Idi Amin years, you couldn’t even get a woman to speak out loud, you know, if men were in the room. The only way you could have conversations with women was to go off privately, woman to woman. Now you’ve got women encouraging their daughters to go to college. The university enrollment rates of females are skyrocketing. You have— you see more and more female attorneys in particular, more and more women entering the roles of healthcare workers. And there has been a delay in first sexual activity by girls, because more and more of them are saying no to the sugar daddies and saying no to the tough boys. And so instead of being— having their first sexual activity at age 12 or 13, it’s now up at 16. Maybe it’ll get up to 17. That’s all good news, and that all shows a positive trend, but it’s not because of religious fundamentalist efforts there. It’s really because the women themselves saw— “Look, we’re powerless. Our husbands bring HIV into the home. We can’t do anything. We don’t want our daughters to experience the same horror.”
KRISTOF: Thank you. We’re at the magic hour, and I don’t want to break the Council’s reputation for punctuality. But for those of you who do have extra questions, you know, please mob Laurie and Isobel after this. [Laughter] And now there’s going to be a break. And please join me in thanking Isobel and Laurie for their remarks. [Applause]
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