Maternal Health and Foreign Policy Symposium, Session 2: Finding Solutions

LAURIE GARRETT: Good afternoon. My name is Laurie Garrett. I’m the senior fellow for global health here at the Council on Foreign Relations. I want to thank you all for joining us.

I think all of you were—or nearly all of you were at our earlier sessions where we laid out, under the moderating skill of my colleague here at the council, Isobel Coleman, some of the key issues responsible for the ghastly situation we have with maternal health.

A few housekeeping details. We are totally on the record here. Everything is attributable and quotable.

We will have a brief conversation here on the stage followed by questions and answers involving all of you in the audience, and then cocktails afterwards, for which we hope you will stay and continue the discussion and the questions.

We’ve already heard some of the numbers, and we have included in all of your kits today detailed data, fact sheet with some breakdowns on maternal mortality rates around the world that should help guide some of our conversation.

I was recently traveling around in Haiti looking at health issues in that country. I was very struck that we now have a fair number of programs on the ground in Haiti, even in very distant, mountainous, rural areas that are virtually impossible to reach by car, to address HIV/AIDS, to address child vaccination, but virtually nothing on the ground for maternal health in Haiti.

Right now the number one cause of death in Haiti—which is just minutes, really, by plane from New York City—is water-borne disease; the number two is death in child birth, death of the mother.

And in—if you look at the data sheets that we provided, one out of every 29 births in Haiti is a fatal event. That’s—for the mother—that’s a striking a figure, and one that speaks to what is it that we’re really trying to accomplish here.

With us today—also in your fact sheets you have the biographies of our speakers, and rather than spend a lot of time going those, I’ll just say a couple of key highlights, and leave it to you to read them in further detail later.

I’m ecstatic that the two people you have here this afternoon, on my right and left, are really—well, if I were just to throw a dart at a dart board and say, give me the two greatest speakers on this subject, I couldn’t have done better.

Mary Robinson—again, you have a long list of her accomplishments in the bio. The one that I love is that when she was president of the very Catholic Ireland she brought in birth control policy and family planning in Ireland in a big way. And that’s an outstanding accomplishment spoken as a half-Irish here. But also, as you will see—I mean, we could spend an hour just listing her many accomplishments.

And on my left, your right, is one of my true heroes, Dr. Allan Rosenfield, who is dean at the Mailman School of Public Health at Columbia University.

But one of the most important things that—is the reason I’m so happy Allan is seated here today is there are two papers that were distributed out front. If you didn’t get them, you can go pick them up as you leave. The first appeared in the Lancet almost to the day, today, 21 years ago, in 1985. Allan, it was titled “Maternal Mortality: A Neglected Tragedy: Where is the ‘M’ in MCH,” as in mother-child health?

In that you said, and I—and I want to just leap right into our discussion policy with this point—you basically said that the issue boiled down then to the World Bank. And you ended your argument by saying, we suggest that the bank makes maternity care one of its priorities. A program for the prevention of maternal deaths could be built around the building of maternity centers in rural areas, the recruitment and training of staff for the centers, and the provision of supplies and drugs. The program could be phased in so the governments would take over these expenses over time. Loans for these purposes should be seen as an acceptable long-term investment in improving the health of women.

What happened? Did the bank do it? (Light laughter.)

ALLAN ROSENFIELD: No. What the bank did do is we had meetings following that paper with the bank where they organized the first meeting on maternal health, which was in Nairobi in I think 1986, if I remember correctly. And that was where the concept of safe motherhood was born in a planning meeting for that meeting by one of the staff people at the bank. The reason why we had chosen the bank as the leading group is the bank does build infrastructure. The bank makes loans. I’m not a fan of loans personally, but the bank really helps build the health infrastructure more than most other—most other donor agencies. And I felt at the time that the health care system that Lynn and Geeta were talking about was core to trying to develop a maternity care system and that the bank was, among all the donor communities, the most likely to be able to support that. They agreed. They held the meeting. But they never really developed a program that I felt they could and should’ve developed at that time.

We have not seen dramatic advances in the last 20 years since that Nairobi meeting at the level I felt—there is almost no country that I can identify that was at the beginning doing nothing that has a dramatic success story today. It is true that Sri Lanka, Malaysia date back to the ‘60s in their commitment to maternity care. But none of the countries that have not made that commitment have really developed a national model. There are some states, some areas, parts of Bangladesh where some (interesting things ?) have happened, but it has not been a national effort the way I think it should be.

GARRETT: Well, and then you flash forward about a decade from the Nairobi meeting. You have the introduction of antiretroviral therapy for treatment of HIV in the wealthy world, tremendous success rates with extending life expectancy dramatically for people infected with HIV. It takes a few years for the achievement in the wealthy world to be totally comprehended and become a major political agenda for the poorer world with higher rates of HIV. But by 2000 we have a real momentum, and at the international AIDS meeting in Durban, South Africa, that becomes the number one issue. If people can live longer in the wealthy world because they have access to these drugs, we want to live longer in the poorer world with access to the same drugs. So then we see this whole political momentum around it.

A year after that, you once again make trouble, and you publish an article entitled, “Where is the ‘M’ in MTCT,” which is mother-to-child transmission, meaning treatment for preventing HIV transmission from an infected mother to child. And in it you said, in 1999 an estimated 500,000 neonates were infected with HIV during the prenatal, intrapartum or breast feeding periods. Where is the M in MTCT? Although the anti-HIV benefit to infants is clear, there is no benefit to the women. What happened from that?

ROSENFIELD: Well, in fairness, when the program for the—what’s called prevention of maternal-to-child transmission, started with a single drug called Navirapine in about 1998. That was before the world had decided they were going to pay for antiretroviral therapy in developing countries. So Navirapine was very inexpensive, and it was a single dose to the mother at the time of delivery and to the baby at the time of birth.

And one of the South Africans organizing the Durban meeting actually invited me to give a plenary talk, and he chose my topic, because I didn’t. He said, your topic is, where is the M in MTCT programs? And I looked at him—(inaudible)—a woman to deliver a drug to the baby, and then you walk away from the woman, and she’s going to die, the baby is going to be an orphan. Why can’t we, now that they’re beginning to talk about money for antiretroviral therapy, which did come out of a call by Kofi Annan and Jeff Sachs and others at the 2000, let’s focus on women. And the MTCT—(inaudible)—initiative that grew out of that was a program focused on women, getting treatment to them, their HIV positive children, and the family, the family-centered approach.

And I must give credit to a foundation that’s represented here tonight. The Rockefeller Foundation was the foundation that was interested in that, helped fund the initiative, and brought in several other foundations to join. And that program has grown into one now that has built into the PEPFAR and the global fund a focus on women and families. UNICEF has played a major role, as well as WHO. And there now is a great deal of treatment of women and the concepts that women deserve treatment, not only to prevent orphans but because women deserve it because women should be treated equally, and particularly in many of the poorer countries.

As we’ve heard in the earlier discussion, women do not have the status they should have, and women should be equal. And if anything, the AIDS pandemic has affected women very seriously because women do not have choice, particularly young women, about sexual activity. And many, many women are subject to HIV seropositivity because of sexual activity, or even young women who are married at age 14 or 15 to a man who has been doing his thing for a few years and comes in HIV-positive to that wedding.

So it’s—I think we have succeeded in getting attention to women there, even more than we did with maternal mortality.

GARRETT: This whole view of woman as vessel—her role is to have the baby, but we’re not directing health intrinsically to her but, rather, to enhance her vessel role—really did become sharply obvious with the question of access to antiretrovirals, when it was so clearly initially just about, as you said, protecting that baby, that fetus.

But when you go now to the question of why are we so far away from achieving the Millennium Development Goal on maternal mortality? Why do we have countries where it’s actually going backwards, where maternal mortality is actually worsening?

And when you look at life expectancy differential, globally, the longest-lived society, Japan, gets over 80, and the shortest-lived, which is arguably Sierra Leone, is approaching 29. So we’re looking at almost a 50-year gap in life expectancy. That’s ghastly. But the gap in maternal mortality ratios if five logs, five full log scales. And in fact, the United States can hardly be a model when we’re a whole log scale below the top strata countries, including Sweden, Denmark, Norway and Finland.

When you look at that whole question, why a five-log differential and why we’re rolling backwards, what do you see as the key biological or medical reason?

ROSENFIELD: Mary, I’m sure we’ll get to shortly. (Laughter, cross talk.)

The differential between infant and child mortality in poor countries and the U.S. is a smaller difference, as you suggested, than the difference between maternal mortality in poor countries and the Western nations. And that, in my opinion, is because we have that success in child survival movement over the last 20 or 30 years, with a focus on—I think Jim Grant was a great champion in leading UNICEF in this arena back in the ‘60s and ‘70s and ‘80s. And no one was focusing on the health and well-being of women, and there was no attention to the fact that while the numbers are smaller than the numbers of kids that die—because the numbers of children dying zero to five are in the millions, and so there is a rationale for focusing on that—no one really gave attention to women, and it just was not on the priority of the vast majority of poor countries, with the exception of a few that Lynn and Geeta mentioned earlier. There just was no attention to the health and well-being of women. They weren’t valued.

There are many societies—not many, but there are some traditional societies where a woman who has a complication and is home and her husband is not there, she is not allowed to go to a medical facility if she doesn’t have her husband or father’s permission. And if they’re not around, she can’t do it. She can sit there and die, because she is not allowed to go out. That kind of status for women is simply unacceptable. And that is the type of thing that we have to oppose, and it’s taking time. There are now increasing numbers of women’s groups who are taking stands on the role—on the empowerment of women. And it’s a huge issue.

One organization that deserves a lot of credit is BRAC in Bangladesh. When that was founded in the ‘70s, in a Muslim country, one of the very first programs was girls’ education. And today in Bangladesh, if you look at high school, there are more girls in high school than boys in a Muslim country. That’s a remarkable story. Girls’ education is a major issue. Mary and her group have been focusing a great deal on this. It’s a key issue, as we look at how we change the status of women in the world today.

GARRETT: Mary, I’m now turning to you. (Laughter.)

There are very few issues you can think of right now in both U.S. foreign policy, EU foreign policy, and the individual European nations’ foreign policy that reflect domestic agendas as clearly as the whole question of funding for anything related to reproductive rights.

This gets right to the domestic religious agendas, right to domestic political agendas, and ends up playing out in foreign policy.

Can you give us a little sense of how that differs between the key donor countries? Are there real obvious policy differences?

MARY ROBINSON: Yes, I will come to that.

I think what I’d just like to say first is very simple. I’m so pleased to be here on this panel. I’m so pleased that the Council on Foreign Relations has given important time to this subject of maternal health. And we had a wonderful panel earlier this afternoon.

So we can—and I hope we’ll talk about this—we can actually take some actions or help to form strategies that will build on what has been done and really make a difference. But it is important that we look at the kind of issues you’re raised, because I was very aware during my five years as high commissioner for human rights that really from the very beginning, from 1997 when I became high commissioner until 2002, the situation was getting worse. And it was getting worse because the issues were becoming more politicized in relation to funding for reproductive health, for family planning. And I knew from my own work as the high commissioner for human rights, the work of UNFPA, of UNICEF, we were all agreed. We sat around in some dismay when we found that the gains in Beijing and Cairo were actually beginning to be undermined.

And currently the political leadership in this country because of the influence of the religious right have played a very worrying role. Let me tell you where it most affected me; it just brings it all together.

I was attending the conference on sustainable development in Johannesburg in late August, early September of 2002. And it was within about 10 days of when I was finishing my five years as high commissioner, so it was my last world conference.

And there had been a bad decision taken at a preliminary conference in Bali in Indonesia, at the initiative of the United States with support from countries like Syria, Saudi Arabia, Pakistan, et cetera. And it was making women’s health subject to religious custom and traditional practices. I think that’s more or less the language. And Canada realized the danger of this, because that was done out of brackets. So in fact, that was the compelling language of the world conference unless it was modified. So Canada put in a modification which was subject to international human rights standard, meaning subject to the agreements of Beijing and Cairo. And that was in brackets, because that was not agreed.

And for the first four days of the world conference on sustainable development there was an attempt to try to negotiate, to get the Canadian amendment out of brackets, to have—because otherwise, you know, there would be a sort of terrible situation for women. I mean, there was a lot of concern about it. And I was going in one morning to my office, I was going relatively early in the morning, and I met a number of heads of the major NGOs, including university teachers and environmental, because a lot of the people there were environmental people, who were absolutely worried about this paragraph 47. And they said, we’re going to have a picket about this because it’s so serious. And I said—and they said, will you join the picket? And I had to ask myself, you know, am I entitled as an international civil servant to be on a picket. So I went in and I sat down with my colleagues, and I said, look, I have only 10 days left in this job; what can they do to me? (Laughter.) I went out. And actually it was quite important. It was a small, dignified picket. And yes, I was photographed in the paper, inevitably, taking part in this picket.

But I was able to say to a number of leaders afterwards, the president of Mexico and the president of Brazil, and the Irish Taoiseach, and who—they hadn’t been focusing on paragraph 47. And that evening we got enough votes for a formula that modified. But who would be responsible for the wording in Bali? The United States, Syria—this kind of alliance. We’ve seen this in any major conferences. We saw it in the special session, the UNGASS. And there was such disappointment about the decisions of the UNGASS. I can’t understand why there isn’t more effective outing of who are partners in this. And somehow it doesn’t seem to figure that the United States is very critical of the policies of some of these countries, and yet on women’s issues at the international level, these are the close partners. Nobody else of the developed world. Why is it not more of a kind of political issue here in the United States? I simply can’t understand it.

I mean, we know where the influence is coming from. It’s coming from the religious right. But surely in this great country there are very strong voices that could be countering the damaging impact of that.

We didn’t have a formal marking of Beijing plus 10, or Cairo plus 10, because we would have gone backwards. And the reason is that these elements were always there in the countries with strong views about not advancing the position of women. But when the United States internationally allies itself, that’s when the real damage is done. And it is real damage to women, to their health, to their futures, and it is very damaging to the image of the United States. I think it’s part of the reason why we see an increasing frustration and, you know, impatience with the United States internationally.

ROSENFIELD: Mary was the first president of Ireland—woman president of Ireland. Maybe you’d like to be the first woman president of the United States. (Laughter, applause.)

ROBINSON: Well, I do tell a story, if I may, because I was succeeded by a woman president. So I had served seven years. There was an election. President Mary McAleese was elected, and then she did a good job so she wasn’t opposed and went forward for a second term. And I went back for her inauguration for her second seven years. And we both tell the same story in Ireland, the sad story of small boys who weep on their mother’s knee and say, why can’t I grow up to be president? (Laughter.)

GARRETT: Just to clarify, maybe everybody in the room doesn’t know what the UNGASS was, the United Nations General Assembly Special Session on HIV/AIDS, which took place about a month ago, and quite sadly was really a roll back. We really went backwards in terms of policy compared to the resolutions the General Assembly had made in their 2001 special session on HIV/AIDS. And yes, as Mary said, it was a unholy alliance, quite literally, between the United States and the Arab nations, that sank everything in the General Assembly.

And it’s interesting, if you look at the data sheet we provided, take a look at United Arab Emirates and their maternal mortality rates, Saudi Arabia, and so on. In the previous session, there was a little struggling to differentiate which factors played the greatest role in improving maternal mortality, with some emphasis placed on overall health systems.

But these are countries with tremendous resources, with spectacular health resources, with tertiary care that rivals anything you could get here in the United States—and yet abysmal maternal mortality numbers. So there’s clearly more involved here than whether or not a woman can get—whether or not a hospital exists; let’s put it that way.

But let me ask you, as a follow-up to what you were just saying on political activism: We have a problem in that it seems everything to do with women’s health and reproductive health is mired in the abortion issue, both for the left and the right.

For—the phrase “right to life” is about the fetus, not the mother. And the phrase “freedom of choice” is about a woman’s right to choose not to have the fetus, not about a woman’s right to choose excellent health care that she can survive throughout pregnancy.

Is there any way that we can fundamentally move this argument so that it engages both the left and the right in real policy that really makes a foreign policy difference?

ROBINSON: I think it’s striking that this is a problem in so many countries. It’s a problem in my native Ireland. It’s a very difficult issue, and we don’t have to really face it, because Irish women go to Britain for their abortions, and they have them safely there. So we’ve never really had the crunch of having to address that issue. But there is a complete unwillingness to do it, and there have been some difficult court cases, et cetera.

And it’s a very difficult issue to talk about in appropriately human terms. But we are actually trying to address the real issues.

I think that in the context of maternal mortality it’s important to bring out that part of the figures of maternal mortality are in fact what are sometimes called botched abortions. It’s a very sad term, and it even in a way—it’s language that kind of makes it even worse somehow, that something was botched, and who dies.

But when we know that 30 or 40 percent of maternal mortality deaths stem from that in countries of high prevalence of maternal mortality—and I’m learning this with my colleagues as a person who’s interested in right to health, and I want to come to that approach as part of the solution. But I find that it’s very sad that so many panels won’t speak about this. People don’t want to actually have to go through some difficult conversation about how to address this.

We have to have much more emphasis, as I said earlier this afternoon, on family planning. We must prevent unwanted pregnancies. We must have far more emphasis on girls’ education and boys’ education on, you know, the education for responsible living and for responsible relationships, and that means having a commitment to building up responsible social capital we were hearing about this afternoon as well. But if we are going to address this I think with any measure of balance, it has to be on the basis of evidence. It’s only evidence basis that you get the right solutions. And so we should in talking about maternal mortality always bring up the figures of the women who die from—

GARRETT: We’ve had trouble with the U.S. Congress and empiricism.

ROBINSON: Yes.

GARRETT: That might be an issue.

ROBINSON: Yes, I know that problem.

ROSENFIELD: It is sad that in all the discussions on issues around reproductive health, family planning, maternal mortality, when the U.S. government—particularly this administration—goes to meetings on—U.N. global meetings, every one of those words, they think, they want struck because they think it would lead to a discussion of abortion.

So if you’re talking about reproductive health, no, we can’t talk about that. You talk about maternal—no, we can’t talk about that. And on and on. And I would agree with something you asked earlier. There is a much larger religious majority than the right wing groups in this country. And the religious groups of our country should be coming together, those that are in the middle and to the left, together to fight the much smaller numbers of the religious right that have such incredible control in this Congress at the present time under this administration.

So many of the decisions that impact on women and many other things are based on ideologic thinking, not scientific evidence. And we need to pose that much more strongly than we have to date, because it’s wrong.

GARRETT: One last question to both of you, and then I want to give the audience a chance to participate. I think we’ve raised a lot of hotbed issues that should get an eager response from the audience.

But from our count here at the Global Health Program we think that there have been in the last 12 months 15 bills put before the Senate or the House in the United States that attempted to insert maternal health language into such things as tsunami relief, into various Millennium Development Goal language, to foreign ops appropriations in both the House and the Senate, even into a bill recognizing the importance of breast feeding. And in every single case, even into bills related to assistance programs in Iraq, and in every single case these bills have been killed—never got out of committee, never got to the floor for a vote—because they have language, as you said, that might go to the question of abortion eventually. The word “abortion,” the actual word was never in any of them, but they did speak to maternal health.

If there is not the possibility of finding some common ground that simply says the right to life is the right to all life, if you accept that a fetus has a right to life, does not a mother also have a right to life? Can there not be some way to forge an alliance that goes to the core Christian principles of this country, Islamic principles in other countries, and so on, that defines this right to life, some essential component of foreign policy and policy planning?

ROSENFIELD: I think when people have tried to come up with the term safe motherhood, that was part of the thinking, because safe motherhood was not controversial in the same way right to life is.

Right to life does—because of the work of reproductive rights people, right to life is a—it does lead to a very—it’s hard to change something once it’s established.

Safe motherhood, on the other hand, I did not think was great terminology, because there are many women who die in pregnancy not because they wanted to be—have a safe pregnancy; they didn’t want to be pregnant. And in Latin America, particularly, abortion-related deaths were probably the number one cause of maternal mortality in many parts of Latin America where unsafe abortion was very common.

So—but safe motherhood was developed by the bank with that thinking, that that would be a noncontroversial terminology and that people might buy into mothers and making it safe to be a mother.

GARRETT: It didn’t work?

ROSENFIELD: Didn’t work—well, they got a lot of publicity, but it didn’t change programs.

GARRETT: Mary.

ROBINSON: I think it’s not really the answer that I think you’re expecting in a way from the question, but I think if we can actually address maternal mortality with the priority it deserves, it in itself will speak to the right to life of the mother.

So in a way, following the very good framing of the earlier section, I felt that there was a need to see where are we in addressing politically maternal mortality as an issue. I think it is getting more priority, and this discussion here in the Council on Foreign Relations, as I said, is important. And there are measures being taken, and there are issues in relation to what the donors are doing that I also wanted to just touch on very briefly.

For example, women’s leadership is beginning to get very interested in this issue for the first time. I mean, it’s quite shocking that this was never a lead issue in the women’s movement. It is now.

I’ve just come from a—(inaudible)—Lynn Freedman was also there—where there is a global network of women leaders on maternal mortality and girls’ education; these are the two issues. And we do see the connections, as Allan has rightly said, and others. And we have a network of women ministers of health that we’ve been getting together and brought together for the third time during this World Health Assembly. They now have two very good chairs—Charity Ngilu, the minister of health of Kenya, and minister of health of Spain, who had just chaired the main World Health Assembly, very strong on gender. And they’re interested in being more resourced to prioritize maternal mortality. And we had a very good discussion at a working lunch, and we now have some foundation support, and Gates support, to try and build on this and network. And the Ghandi Fund, which I serve on, has allocated $500 million for strengthening health systems. And Richard Feachum (ph) with the Global Fund wanted to do that. I’m not sure if the financing allows.

But I think that we need to get to the mentality—and I’d like to hear Allan’s view on this—where every (vertical ?) intervention, whether it’s on immunizing children, or on AIDS, TB, malaria, or—(inaudible)—or anything that (vertical ?) interventions, that they have to allocate a percentage of their time, of their resources, of their energies, in strengthening the permanent health system and, you know, have that as a kind of priority, because that’s the only sustainable way that we will deal with the future health of a country. And the governments have to meet their commitments. Lynn mentioned the Abuja commitment of African countries to 15 percent. We should be encouraging African civil society to put that pressure on African governments. But we need to strengthen health ministers within their government.

If you allow me just a little moment to go back to a question that I think representative of UNFPA asked about the Paris declaration on aid effectiveness and the fact that there is global—sorry, general budget support now, and from the European donors to African governments. I’m talking about Africa, because I’m particularly focused there. That is really worrying. And certainly ministers of health and heads of health departments in Africa said to me personally in recent visits over the last few months that they’re very worried that this will mean less allocation to health unless something is done.

So this is another reason to both strengthen health ministers and their ministries in what they do. And I’m sure Allan may have heard this story, but I think it’s a very powerful one from the current minister of health of Kenya, who is a friend of both of ours, Charity Ngilu. She increased her health budget I think by about 30 percent by tackling corruption in procurement. And then she had threats to our her life, because this was a big issue. But tackling corruption in procurement is a very significant was of increasing a health budget. And then she muscled her way into the government committees that were dealing with the budget, and as she put it to me recently—so it’s her story, and it’s a wonderful story—she listened as the government was deciding on the allocation of the budget, and then she turned to her president, and she said, “President, are we at war with anyone?” And he said, no Charity, we’re not at war. “Then why are we—why have we such a big military budget?” And that got me another 10 percent, she said. (Laughter.)

But I’m quite serious. Ministers of health need to be in on the budget allocation if we have general budget support. And to do that they need to be supporters in their ministries. And so we need to be more holistic in how we galvanize the action for strengthening health systems. But the pieces are there.

I mean the report of the WHO this year, which was launched in London in—(inaudible)—and I was in London for the London launch—was on (the human resources ?) for help. So we’re all talking the same language. I think there has never been a point where there is so much agreement about what really needs to be done. And it’s just how we get the concerted interlinked political action to do it.

ROSENFIELD: Can I make a couple of comments?

GARRETT: Let me ask her one follow-up, and then yes.

Real quick, you mentioned the Paris declaration. But the Paris declaration has a potentially dangerous flip side in terms of maternal health, because it says donors must be sensitive to what the countries want to spend their money on and not try to dictate from the outside. So if you’re country X that legally, barely, has granted suffrage to the females, and still allows the sale of females—slave trade—allows parents to sell their children and so on, how in the world can it be that that portion of the Paris declaration is in the best interests of the women in those countries?

ROBINSON: Well, there is one very useful tool in the Paris declaration, and that is the gender—the cost-cutting issue. So that’s been agreed by both sides. So if there are situations, there has to be movement in the right direction.

And I think this can be used as a leverage. Unfortunately, human rights are not a cross-cutting issue, which many of us felt that they should be. But at least gender is there very significantly as a cross-cutting issue, and they can work on that, I think.

GARRETT: Allan.

ROSENFIELD: Well, first, I’ve said this to Mary in the past: it’s good to get the women and ministers of health together. I wish we could get a bunch of women ministers of finance—

ROBINSON: Yes.

ROSENFIELD:—to join, because the power in countries’—ministers of health in most countries are not among the stronger ministers; they’re among the weaker ministers, not because they’re not individually good, but because the ministries of health aren’t in the top priority level. Ministers of finance, on the other hand, have tremendous power, sometimes ministers of interior. I’d like to see a bunch of women ministers of finance and bring them together, because they can begin the allocation of appropriate resources.

GARRETT: How many can you name?

ROBINSON: And I think that’s doable.

ROSENFIELD: I don’t know how many there are.

ROBINSON: Unfortunately, the very good minister of finance in Nigeria has just now been made minister of foreign affairs. So that is one strong minister.

But there are—there are several in Africa alone.

ROSENFIELD: But I wanted to make just a couple of comments on the health care system, following up on some of the discussion earlier and some that we’ve had just now.

And it’s interesting, in my own personal career, when I started working in family planning—I don’t know, 80 or 90 years ago, it feels like—in Thailand, at a time when oral contraceptives had just been introduced, and only doctors could prescribe oral contraceptives in Thailand at the time. And I was an obstetrician; I am an obstetrician. And I (felt the day ?) before I had to get approval in the States. I worked with the Thais, and they said, it doesn’t make sense; we are about 150 doctors in the entire country outside of Bangkok; there is no way women can get the pill. We trained auxiliary midwives who were high school graduates, had a little bit of training, and all of a sudden we did this test and it worked, and we had over 3,000 people who could prescribe the pill and break it out of the medical model. Then we trained people to do IV insertion and various other things.

In the area of maternal mortality, we have a huge problem in many poor countries in that you need access to 24-hour coverage, seven days a week at the district level. And there are very few doctors and nurses who work at the district level. And we have examples now in Mozambique, Tanzania and Malawi where nonphysicians have been trained to provide emergency care. And this is a great model. We’re going to be holding an international meeting on the results of the work that they’ve done.

Some of you know Pascoal Mocumbi, who is the prime minister of Mozambique, who was minister of health about 15 years ago. And he’s an obstetrician-gynecologist. And I think at that time there were something like seven obstetricians in the entire country; all of them were in the capital.

And he and actually someone from Colombia developed a training program, and that has now expanded where they have many of their hospitals, many of their district locations, where these people are providing that care.

The same model is going to be important in the AIDS issue. If we are going to get care and treatment out to people in rural communities, we are not going to have infectious disease doctors available in the rural districts to provide that kind of care. We’re going to need to train local people.

Just a comment on the brain drain that you mentioned I think earlier.

There are a couple of issues that I think are priority. Aside from the job descriptions of who can do what, we also ought to be working very hard to increase the pay scale for doctors and nurses. There are many people who migrate not because they necessarily want to leave their country, but the pay scales are so low that they can’t afford to bring up their families. And many people—not only brain drain by going to U.K. and U.S., but if you look at the universities, the NGO, the U.N. system, we all hire local people and pay them at a higher level. And once they’ve gotten that salary level, they can’t really return, because they are used to getting a reasonable salary.

One of the key issues it seems to me is to change the salary scale in the health care field—many people would stay home if they got a reasonable salary—and redefine who can do what where, if we want to get care out into the rural districts. And for maternity care this is essential. We’ve done a lot of that in child survival. We’ve trained people to prescribe antibiotics for respiratory infections, with a checklist to do other things at the level of the community. And we can do some of that in maternal health as well. But there are certain places where we’ve got to have the emergency care that’s essential to save the lives.

People are very focused on fistula. Nick Kristof has done a great job, and so has Oprah to an extent talking about the fistula issue—women who develop a vaginal link between their bladder and their vagina or their rectum and their vagina, and they leak urine and/or feces. And for many women in many countries, they would have actually been better off dying because they become a total outcast. They’re thrown out by their husband. They won’t be taken in by their own family. They live as outcasts until that fistula can be repaired, and the priority is to prevent the fistula from forming. And again that is the same issue as preventing deaths.

So I’ll stop there.

GARRETT: I’m going to let all of you take part now. As always, please wait for the microphone to reach you. Raise your hand if you’d like to ask a question. And please identify yourself when you do ask a question.

Questions? Over here, from UNFPA again.

QUESTIONER: My name is Mary—(inaudible). I’m from UNFPA.

I would just like to ask, because in the past and in the really remote past the issue of maternal mortality has been framed within the human rights perspective. But then in the 1980s I remember that maternal mortality has increasingly become framed within the economics perspective, so that instead of invoking, for example, maternal—(acts ?) of right to life as a basic fundamental right, we now have to ask first how cost-effective are these programs. And often—not often, but most of the time, cost-effective analysis show that emergency obstetric care are the least cost-effective of all the options.

And so I know, I appreciate that human rights and economic arguments stem from the same root. But how now can we move this discussion forward, so we will not always be debating on whether, are they cost effective or not?

ROSENFIELD: I would sort of take exception to that. The cost of setting up—(inaudible)—facilities is not that expensive, and we have data to provide on that. But most important, if a woman has the basic human right to have access to maternity care, cost-effectiveness should not be the basic argument. And that’s why a country like Sri Lanka has decided maternity care is important. Every Western nation has decided maternity care is important. There is not a single Western nation in which women don’t have access to maternity care as their basic right.

Cost-effectiveness should not be an issue, but even if it is, it’s not that much that out of range of other essential health care services. It’s a hell of a lot cheaper than the HIV/AIDS response for providing antiretroviral therapy to women and men who are HIV positive and children.

GARRETT: Let me ask you, Allan, and Mary, do you think if adult men had a life function that potentially could kill them once every two or three years cost-effective analysis would be used to determine whether or not they ought to be treated for this?

ROSENFIELD: It should be for men, but not for women. (Laughter.) I would not.

GARRETT: I wonder if the cost-effective analysis is basically a reflection of the relatively low earning power of the female.

ROBINSON: I think it comes back to that. It’s all about who’s got the power and the value of women and the girls. But I must say, I have found it a great pleasure personally in working closely with the Mailman School of Public Health, with people like Allan and Lynn Freedman—they adopt a very human rights approach. And that obviously is the approach I’m coming from. We’re trying to make operational what it means to say that you have a right to health. And we got together a group of health experts to the Wye River complex in June of last year, and we adopted the Wye River Call to Action on women’s health. And it’s not written in U.N. speak; it’s written in really strong language, and it is making quite a wave.

I had an interesting occasion before the celebration of Mother’s Day in the U.K., which is different from the date of Mother’s Day here—it’s in mid-April. And there was an event in the House of Commons organized by the World Health Organization, the Health Section of the Commonwealth, and some women MPs who brought together a number of MPs, men and women, for the marking of Mother’s Day with a big Mother’s Day card, lovely for the soft roses, et cetera, on the outside of the Mother’s Day card. And you opened it, and there was the Wye River Call the Action. And MPs were signing up, including two health ministers.

That’s part of an illustration that if there is a right to health approach, the advocacy is much stronger. It’s shocking what the figures that we’ve been looking at, your fact sheet—absolutely shocking and unacceptable. It’s shocking that it hasn’t been a priority of the women’s movement. It’s shocking that there hasn’t been more action.

I absolutely agree with Allan: of course we need the finance ministers. We also need these health ministers in developing countries to link with the development ministers of the donor countries. And we need to make all kind of linkages. But what we do need to do is to support the schemes that show that on the ground this can be tackled. I mean, I saw with Lynn in Tanzania a scheme that was illustrated—one of the poorest regions of Tanzania—and it worked. You could see the graph of success on maternal mortality.

So it’s not as if we don’t know what needs to be done. And it’s not a cost effective; it’s absolutely a human rights issue of incredible proportions.

And I do think that it’s also a political issue, as I said, and a women’s leadership issue. And we need to harness the different components and the different interventions on health in developing countries and make them all work for strengthening the health system. That to me seems part of the key to addressing maternal mortality which needs a functioning health system.

ROSENFIELD: Just one comment. The first time I gave a talk after Lynn educated me about human rights—and to a large American audience—you know, I was halfway through the speech talking about the right to maternity care and how this was a basic human right. In the middle of my talk a bell went off in my head. What about low income people in the United States who don’t have health insurance? Don’t they have the same basic human right? There are 40 (million), now 45 million people who do not have access to health care insurance, 70 percent or so of whom are working poor people. That’s the same basic human right that this country—it’s really an obscenity in this country that we’re a wealthy country and we allow that many people not to have any access except to an occasional emergency room care where they don’t get any kind of continuity of care.

GARRETT: If you look at the logarithmic differential in maternal mortality between the United States and Northern Europe, do you think that boils down to that health care access question?

ROSENFIELD: Well, the difference, actually, our difference—if you compare the U.S. to the developing world, we are so very low. We’ve got a maternal mortality ratio of about 12 to 14 per 100,000. There are countries in Europe that are maybe eight to 10. It’s not a huge difference. But there are differences in low-income people. If you do an assessment in New York City, low-income minority women have a much higher rate, not like developing countries, but a rate that should not be the difference than it is, because they don’t have easy access to good maternity care services.

GARRETT: Let me get another couple of questions in. Over here.

QUESTIONER: Hi, I’m Ella Goodwin with the Population Council. One of the issues where you have some cooperation between secular groups and religious groups is on the issue of child marriage. And I’m wondering if you could just speak to the power that focusing on that demographic has politically, and the kind of leverage that might be gained there. I believe in countries like Burkina Faso 80 percent of the girls have babies before the age of 20. So if you could just speak to that, please.

ROSENFIELD: Well, one comment, both for pregnancy and for HIV: If you look in several African countries, the ages of 13 to 18 or 19, there are dramatically more HIV-positive young girls than there are boys, because they are having sex with older men, and it doesn’t equalize until into their 20s. There are also many women having—in some countries—having children at age 15, 14 or 15, as was mentioned earlier. That should be a major campaign against child marriage and protection of young girls against sexual—forced sexual activity at a very young age. And that’s a huge issue, I think, for the world to focus on.

ROBINSON: And this again links with the emphasis that was put earlier on girls’ education and girls’ staying in school and staying in school at second level, and hopefully even going on to a third level, and the practical incentives that are needed.

I mean, I’ve heard of some practical programs that make a difference where no fees for school books, no fees going to school, and then if a girl is still in school at the age of 15 she gets a bicycle, and if she’s still in school, you know, at the age of 17, she may get a scooter. These kind of real practical—to make her an important entity in her family. If you’ve got a bicycle, then, you know, somehow—these may seem artificial but they work—practical incentive to ensure—and in particular, to work from within to tackle a child marriage.

Again, I’m kind of uncomfortable about kind of preaching from outside. It has to be worked on from within at village level. And for that the girl has to be important and the girl has to be able to protect herself, or otherwise, we’ll have the terrible statistics that Allan mentioned.

I mean, it is horrific, and the—I mean I’ve heard it said that, you know, young girls in some countries in sub-Saharan Africa are becoming an extinct species because they are so vulnerable and so unprotected. And the marriage is part of that. And a young girl is more—is less likely to be able to protect herself in marriage in many circumstances.

GARRETT: In December I was in a place called—(inaudible)—KwaZulu-Natal, where the infection rate in girls under 18 is 27 percent.

We have time for one more question, over here.

QUESTIONER: Hi, I’m Theresa McGinn (sp) from the Mailman School of Public Health at Columbia.

We’ve been talking about in both panels actually the responsibilities of governments to take on these issues. But I’m wondering also about the issues of refugees in displaced populations, refugees who are hosted in a country which may feel they’re a burden, may in many cases help them quite a bit, but displaced, who live in countries where their very governments either won’t—kind of choose not to or can’t support them in all these issues—you know, maternal health among them. I’m wondering your comments on those—on that topic.

GARRETT: Mary, that’s really (your ?) ballpark.

ROBINSON: I’m glad you kind of particularly focus on the internally displaced. Yes, there are very big issues in relation to the refugees, but they have the Office of High Commissioner for Refugees; they have support of a number of civil society organizations. And the internally displaced can be much more difficult because governments don’t want to admit how many there are. It’s their problem. You know, it’s an internal domestic problem, et cetera. And yet you have millions of internally displaced.

And of course, you have now in Darfur internally displaced in awful circumstances. But for a long time, Colombia, a huge population of internally displaced, and they do not get adequate—

ROSENFIELD: Columbia University? (Laughter.)

ROBINSON: No, not Columbia University, sorry. And I mean, eventually there will be guiding principles for internally displaced to create standards for governments. And even those governments were very reluctant to accept—but more work is being done on that.

But it is a huge issue, and again, it’s—I feel that if we can have a more concerted approach to health systems generally, it will ultimately help the internally displaced.

GARRETT: I lost track of the time. I thought we were almost ready to wind up. But we actually have time for plenty more questions. And I’m sorry if I was being a bit abrupt. My apologies.

Any additional questions for just a moment. Excuse me?

Over here.

QUESTIONER: I’m Helen Depina (ph) from Columbia University.

Perhaps just to go back to the cost-effectiveness issue, and it also goes back to what Lynn Freedman was saying earlier about how we frame, how we measure things. And what are the kind of outputs that we’re measuring and the impacts that we want to measure in cost-effectiveness?

And certainly we’ve seen that just looking at EmOC as an intervention may appear costly, but if we look at the externalities, the positive effect of strengthening a health system simply to produce EmOC has enormous impact on strengthening a health system at the district level that can deal with other emergencies and other issues at that level. And I think it’s very dangerous just to focus on a single intervention and look at its costs without saying how does this fit into the whole health system strengthening?

ROBINSON: I agree very much with that. In a way, I’ve been looking at that from the other side, on the Garvey (sp) Fund where there’s been an allocation of $500 million for strengthening health systems, but it mustn’t be just to get more children to immunize more children. It’s strengthening health systems. And I think—and that’s where we do need more holistic approach. And then the gains are enormous, because we all know the link between health and development and the importance of that.

And if I may, I wanted to be able to take up—and I might (not ?) get another opportunity—some of the discussion earlier on the brain drain issue, because actually I came from a meeting this morning talking about migration and development and the dialogue of the General Assembly in September. And I think there is a real opportunity to look at the brain drain, brain gain, brain circulation that we spoke about when I took part in the Global Commission on International Migration, and look at practical measures to address the movement of health workers.

I very much agree with Geeta Rao Gupta that the individual should not be stopped. But where you have such pull factors—for example, here in the United States—some countries like Ghana, where I was recently—in New York alone you have 600 Ghanaian doctors. In the whole of Ghana I think you have just about two and a half thousand. And so you know it’s a really significant number.

Is it possible to envisage having a Ghanaian diaspora working with the two countries, both the receiving country and the sending country, on issues of co-development, on training more doctors and nurses in Ghana, if that’s the solution, so that some of them will stay and others will go, but at least there’s a payment for the training, and other kinds of measures for compensation.

And I think in particular, the point of focusing on health workers is to see some health markets—if I could put it that way—as being actually one single health market. The United States needs, as I understand it, some 500,000 nurses and 200,000 doctors between now and about 2015, but it’s not training anything like that number. So therefore, it’s in a kind of health worker (market ?) with Ghana—(laughs)—or with the Philippines, in the case of a number of countries including Ireland, modern Ireland. So how do we compensate effectively in a way that helps build up the health resources in the sending countries as well as the benefits that come to the richer countries that benefit from this.

GARRETT: We had a rather lengthy meeting on this topic here at the Council on Foreign Relations about three months ago, and a couple of issues came up. One, raising the salary levels of nurses and doctors in most poor countries to reach a level that would prevent a desire to leave the country would so vastly increase their income as to create a tremendous inflationary pressure on the overall civil service sector, and for many countries would be an intolerable inflationary pressure. Another concern has to do with our immigration bill which is currently in some floundering state in Washington; we’ll see what ultimately happens to it. But of course, built into that bill were a whole series of exceptions specifically for health care workers. So all the rules discriminating against immigration stop, full stop, if you’re talking about bringing nurses from the Philippines or doctors from Ghana. And this then goes to the heart of a larger set of foreign policy concerns for the United States.

Let me take another question here in the front. Here comes a mike.

QUESTIONER: Yes, it’s the same question I asked earlier, and you said please repeat it. (Laughter.) So it’s how to deal with the donor nations like the United States that will build health care systems somewhere as long as there is no abortion or family planning connected with it. And aside from of course throwing them out of office, what else can we do?

GARRETT: Let me just add to that question. Since we were just talking about health care workers, we’ve also been presented with a substantial amount of evidence here at the Council on Foreign Relations that American foreign programs, particular PEPFAR, the President’s Emergency Plan for AIDS Relief, and NGOs, American NGOs, are so—paying health care workers so much more wherever they are on the ground in the PEPFAR-targeted 16 countries that they’re actually becoming a sort of vacuum effect to pull health care workers regionally out of countries that are not PEPFAR countries, because by going to a PEPFAR country they can make 10, 15, even 20 times their income that they were making in the neighbor state.

Could you go to that question.

Allan, do you want to go first?

ROSENFIELD: Let me just—even this administration, there still is funding, international funding for USAID for family planning programs—not for abortion, but family planning is still funded by the U.S. government, which is amazing given this administration.

But during the Reagan administration and first Bush administration and this Bush administration, family planning funding is not at the level we want it at but it still is there, and USAID does fund family planning programs.

Many of us who get—are involved with PEPFAR-related activities are building family planning services into our PEPFAR programs as well—

MR./MS. : Sssshhh!

ROSENFIELD: Quietly. (Laughter.)

Abortion clearly is prohibited by law. You can’t fund abortion-related activities. But many organizations don’t buy into the Mexico City clause that says you can’t with other monies provide services, and many groups still do that. The Mexico City clause is a problem.

GARRETT: You might explain to people what that is.

ROSENFIELD: An organization overseas that is getting U.S. funding cannot be providing abortion-related services, even if it’s legal in the country, with other people’s money and still get U.S. government money, and that’s an objectionable clause that we all try to fight. But in terms of family planning services it is not supported the way it should be, but it is not illegal to have that as part of a U.S. program.

Unfortunately, the rest of the European countries, when the U.S. cut out UNFPA, the other European donors replaced the U.S. money in UNFPA with European donor money. So there is now—there’s still a lot of unmet need for family planning services, but it’s not banned.

ROBINSON: I think it’s also relevant to look at the evidence of what we were talking about earlier, the vulnerability of girls, and particularly in countries like sub-Saharan Africa, where, you know, between the ages of 15 and 24 they’re, in some cases, as much as six or eight times more likely to become HIV-positive. And that’s not because they’re bad. And so one can work on, you know, what works and what doesn’t. And abstinence isn’t the reality in some circumstances where there is rape, where there is sex for food, sex for—

GARRETT: Where there’s marriage.

ROBINSON:—where there’s marriage—and to probably talk more and with those who are trying to influence them.

I mean, again, I very much agree that there is a need for a sort of moderate religious reaction on these issues based on the evidence about maternal mortality, the evidence about the vulnerability of girls to becoming HIV positive, and the need for and approaches to reproductive health, approaches to family planning, which are actually, as we know, if done properly, reduce the incident of abortion, which is what everybody wants.

GARRETT: So pretend I’m Senator Brownback of Kansas. (Laughter.) He is a deeply religious man. He has actually fought very hard for a number of development issues because he does believe that there is a broadly stated right to some level of equality of life out there.

What’s your argument to say, “Senator Brownback, you need to fund these issues”?

ROBINSON: I’m not sure whether Senator Brownback has had the kind of opportunities to sit in a seminar with African women and—on these issues, as I’ve done a number of times and many of the people in this room I think have done. I remember one seminar in Botswana where we were focusing on having women’s leadership and parliamentary leadership on attacking HIV and AIDS. And we had the women speakers the evening before, and every single one of them were saying, what are going to do to try and convince that this ABC policy, although it may be fine in the right context, doesn’t work here and is putting people at great risk? And as we spoke, there was a young Ethiopian student there. Eventually in some frustration she said, look, why do you keep referring to the first three letters of the alphabet, A, B, C? And I said, well, what would you do with the next three letters? And I kind of looked at her. And she thought and said: Don’t eliminate the future. (Laughter.) And there was a sort of a pause in the room, and nobody said anything for a minute. It was just—you know, she was in her 20s, and this was what she said. I think just that reality, you know—the reality of women’s lives is the most compelling argument for Senator Brownback.

GARRETT: Allan?

ROSENFIELD: Well, I guess if I were Senator Brownback I’d try to look at what’s equitable and what’s right. If he is a religious man he ought to do with away with the ideologic aspects of it.

But I think one of the things the U.S. government has been doing very badly is the abstinence till marriage concept and then spreading ill—incorrect information about condoms that they don’t work, that condoms have holes in them, that they—and those two things are simply unacceptable and should be done away with.

As some of you have heard, I do have an answer to the abstinence: that that’s okay as long as you use moderation. (Laughter.)

GARRETT: That’s really Confucian of you. (Laughter.)

ROSENFIELD: The whole abstinence till marriage, when they do not allow education about prevention—even if it is ABC, in schools, in some of the programs, in (a lot of the ?) prevention programs, they talk about that—that is immoral and wrong. We need to let people know how to protect themselves, and that includes understanding what condoms are and not giving misinformation about condoms.

ROBINSON: And also promoting female condoms much more.

ROSENFIELD: Yes. And promoting the research on microbicides, which could make a huge difference if we ever get that through. And that’s one of the things I think the Gates Foundation is putting a lot of money into, and I’m hopeful that within the next three to five years, long before reaching a vaccine phase, we will see a microbicide, I hope, available that will allow women to be able to protect themselves.

GARRETT: Let me ask you both a final question by way of wrapping up. We have a Millennium Development Goal agreed to by the United Nations, which the U.S. Congress has agreed to as part of the Millennium Challenge Grants, and that is to reduce that ghastly 500,000 maternal deaths a year by 75 percent by 2015. Is that doable?

Mary?

ROBINSON: I think it is doable if we address, as we’ve said on both sessions of this, the need for a holistic approach to the health systems. And that is not impossible, and it’s not all that expensive because of the gains that would come from having a functioning health system.

And in a sense, the health systems of some of the poorest countries—in Africa, again, is where I have the more direct experience, and they are worsened by policies of structural adjustment at the IMF and World Bank. They kind of weakened already weak systems. Now we have to reinvent the state, not in a 20 th century way with bloated bureaucracies and perhaps corruption, et cetera, but actually working for smart management of the various interventions so that all of them work to strengthen the health system, and we put a strong priority then on maternal mortality in that context and do the practical things that work at local levels, which the Mailman School and others have been proving are the right approach.

So I am glad it’s a higher issue, the international women’s agenda. I’m going to be in Senegal shortly for an umbrella group of African women, AWOME (ph), and we’re going to talk about maternal mortality, girls’ education. And we need to link—you know, fire at the top and fire at the bottom of the women’s movement, get moving, but also the wider political—you know, these ministries of health definitely linking with other ministers in their cabinet, make it an issue of human resources and connecting the component parts that will strengthen what were very weak health systems.

There’s a huge potential of telemedicine that we haven’t talked about, e-medicine, and proper applications to ensure that there are those connections made.

In other words, I’m not a health expert as such. I’m a right-to-health fanatic. (Laughs.) And I do see politically that it is possible to reach those—that girl by 2015. And we know where the high prevalence is, in sub-Saharan Africa and South Asia. We need to target very effectively and get the political will on that.

But I really do think it is doable, particularly if this is an issue that the Council on Foreign Relations and other bodies like this will keep running with.

GARRETT: Allan.

ROSENFIELD: I think you all read about the transaction that took place yesterday between the Buffett family and the Gates family. And I do think that one of the areas that the Gates Foundation is now giving more serious attention to is the health care system and developing means to improve the health care system.

And I think maternal health and child health is going to become a part of the next five years of Gates’ attention. And so I think that will help, because they provide great leadership in the health care, global health arena. And I think they are going to be moving—they’re still very happily focused on the technology and AIDS vaccine and things like that, but they now are beginning to talk about looking at this kind of an issue, and I think that’s going to be very important, and we’re having some discussions with them on that topic.

GARRETT: On that note, President Robinson, Dr. Rosenfield, thank you so much. And thank you to all of you. Please join us now—(interrupted by applause).

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