Women's and Girls' Health in South Asia: Challenges for Global Policy

October 28, 2003

Made possible by the generous support of the
Bill & Melinda Gates Foundation.

Panelists:
Lucille Atkin, Director of Margaret Sanger Center International/ Vice President of International Programs, Planned Parenthood of New York City
Nirmal Bista, Director-General of Family Planning Association of Nepal
Kati Marton, journalist, human rights advocate, Board Chair, International Women's Health Coalition

Moderator: Adrienne Germain, President of International Women's Health Coalition

Sheila Platt: Good evening and welcome everyone. I am Sheila Platt. I am a member of the Asia Society and also a social worker and my work in the Philippines and in Pakistan and particularly in Zambia, among other countries, has for many years involved refugees and displaced persons. I saw the beginning of the HIV/AIDS pandemic while living in Zambia in the early 1980s and I have been very aware ever since of the dreadful effect that is happening in Zambia and elsewhere to women's and girls' health and human rights.

The Asia Society is very pleased tonight to host a timely and important program, Securing Women's and Girls' Health in South Asia: Challenges for Global Policy. The panelists will discuss the critical challenges that lie ahead in securing reproductive health rights for women and girls in South Asia. They will in particular look at the impact of HIV/AIDS on women and girls in the region and consider strategies to address the growing crisis. They will argue that women must be at the heart of health policy debates, both in the US and abroad. It is my privilege to introduce tonight's distinguished panelists.

At the far side we have Adrienne Germain, president of the International Women's Health Coalition. Then there is Kati Marton. She is an award-winning journalist, a human rights advocate and the new board chair of the International Women's Health Coalition. Congratulations, Kati. Then we have Dr. Nirmal Bista, Director-General of Family planning Association of Nepal. And finally we have Dr. Lucille Atkin, Director of the Margaret Sanger Center International and also vice president of international programs, Planned Parenthood of New York. You have more information about the speakers in the program.

Tonight's program is part of the Asia Society's Asian Social Issues Program, known as ASIP around here. It is a public education initiative that looks at the critical social challenges and emerging strategies to address them in Asia in general. For the last four years ASIP has played an important convening role to discuss issues in human rights, including women's and children's rights, poverty, the environment, conflict, among others. We are also pleased to acknowledge the support of Bill and Melinda Gates, who through their foundation have funded a new initiative, AIDS in Asia. And tonight's event is part of this new initiative.

For those of you who may be new or who are coming here for the first time to the Asia Society, welcome. And let me take this opportunity to extend the invitation to join us through our various levels of membership and there are membership brochures outside in the lobby. Without further ado, let me turn to our panel and I would ask you to please welcome Adrienne Germain.

Adrienne Germain: Welcome to all of you and thank you for coming to discuss this terribly vital and important topic.

I visited India for the first time thirty years ago, in 1973. Indian colleagues of many backgrounds introduced me to women in isolated rural areas and in sprawling cities. Since then I have returned often to India, Pakistan and Bangladesh, usually focusing on the health opportunities and rights of girls and women. I have always ended my visits optimistic, due to the steadily growing strength of South Asian women leaders and organizations. I have always felt buoyed by increasing awareness of the central importance of improving women's lives, securing their human rights and moving toward gender equality across the subcontinent.

Last week I returned from a two-week stay in India that took me from villages in southern Rajasthan to the red light district of Calcutta and to India's Silicone Valley, Bangalore. I met with NGO leaders and staff, business men and women, government officials and donors. I talked with teenage boys and girls in Delhi's so-called resettlement areas and with young women living with HIV/AIDS. This time, for the first time in thirty years, I came home with a sense of desperation.

In the early 1980s when the first HIV/AIDS cases were identified in the US and Africa, I was living in Bangladesh. As the resident representative of the Ford Foundation, I funded the first ever research in the subcontinent on sexually transmitted diseases. I knew deeply and firsthand the circumstances that girls and women across South Asia faced, circumstances that would make them especially vulnerable to HIV. I had learned from South Asian women and girls themselves about child brides, about sexual coercion and violence, about sex discrimination and education and employment and about the failure of national programs to promote condoms or require men to respect women's rights. I knew and worked with many South Asian colleagues who wanted their countries to address these problems in their own way. I also knew that these countries needed to close the gender gaps that foster HIV/AIDS before it could gain a foothold. And I said so. But back then no one with power listened.

Twenty years later, South Asia is on the brink of an unprecedented catastrophe. Large populations and inadequate national policies and programs mean that the number of people infected and affected by HIV/AIDS in South Asia could dwarf anything we have yet seen, even in sub-Saharan Africa. India alone has an estimated 4.5 million people living with HIV/AIDS, the second largest number of such people in any one country. Some experts with whom I am inclined to agree actually estimate that the number of people living with HIV/AIDS in India is more likely to be close to 10 million and already 40% of these are female, most of them girls and young women. As elsewhere, young people in South Asia are disproportionately at risk, especially girls and young women. Well over one quarter of all the adolescents, the 10 to 19 year olds, in the entire world, live in South Asia. How they learn, what they learn and what they do about sex will substantially determine the course of their lives, their country's progress and survival and the course of the HIV/AIDS epidemic.

In India, HIV/AIDS has already spread to the general population, even to the isolated villages of Rajasthan that I visited two weeks ago. Across India and the entire subcontinent, the epidemic is driven by poverty, drought and other conditions that force men to migrate in search of work. Away from home, they have sex with women in brothels or along the truck routes or on construction sites. They return home to infect their wives and their babies. Other girls and women are at risk from sexual violence or child marriage to older men or unsafe health services and predominantly, ignorance. Most people in South Asia with HIV/AIDS do not know that they have it.

Unless we improve the status and opportunities of girls and women in South Asia and protect their human rights, there is no hope of controlling HIV/AIDS. We know what to do. Advocates, activists, practitioners for women's health and rights, inside and outside governments and across South Asia have worked for 30 years to identify effective strategies and interventions. What is needed now is massive mobilization of both government and civil society to end discrimination against girls and women and abuses of their human rights. Two of our panelists tonight will reflect on what is feasible in India and Nepal.

What about the international community, all of us here? And the global health policy makers and donors? What are we going to do and how well will we help South Asia meet these challenges. Sad to say, for me, right now the glass is half empty, not half full. Global actors are mobilizing to support interventions in South Asia like those used in Africa and the United States early in the epidemic, promoting condom use by sex workers and their clients, protecting blood supplies and working with the gay community and IV drug users. More recently, they have also begun to fund HIV counseling, testing and treatment. These are all critically important.

But for the subcontinent, which still has time to prevent a major catastrophe, these global agencies need to invest HIV/AIDS resources - human resources as well as money-in building reproductive health services and health systems, which are the only way to reach the 70% to 90% of girls and women in South Asia who live in rural villages. Global actors are also not yet supporting universal access to sexuality education for adolescents in South Asia. They are leaving that difficult and taboo task to creative but overburdened NGOs. They are not speaking out about boys' and men's behaviors or demanding that they change. They must and we must.

While global health policies are too narrowly constructed, the Bush Administration's policies are dangerously shortsighted. As of now, and we hope we can change this, none of the President's $15 billion AIDS package is going to Asia. Furthermore, the US government currently as the largest donor and the sole superpower also has inordinate impact on international strategies. For example, the White House and Congress would severely limit funds for condom distribution and comprehensive sexuality education programs. In Washington this week, the Senate is debating international reproductive health and HIV/AIDS funding. On the floor today, Senator Diane Feinstein urged her colleagues to ease proposed constraints on US funds, arguing for the widest possible range of strategies known to slow the spread of HIV rather than narrowly defined and unproven abstinence only programs. As we sit here tonight, the Senate is debating this and other amendments. They will vote tonight or tomorrow. Let us hope they vote for girls' and women's health and rights and their lives.

Let's turn now to our panelists who will provide concrete insights into what needs to be done and the challenges that lie ahead. First I will ask Kati Marton to join me. She and I traveled just this month to India and she will share with you the impact of that.

Kati Marton: Thank you Adrienne. Good evening ladies and gentlemen and thank you for coming this evening to hear what is obviously not a terribly cheerful message but one, which with your help can actually be turned around. I had the privilege a week ago to have the most remarkable guide to India in Adrienne Germain and it was an eye-opening visit for me - only my second. And I am now determined that our organization, the International Women's Health Coalition, will be even more engaged in what is obviously a pivotal crisis for the world and which hopefully after this evening all of you will also feel you can do something about, in whatever capacity you chose.

What I observed during Adrienne and my recent visit to India is the creation of a new caste, lower than any existing caste in India, and it is made up of HIV positive women. No matter that 90% of these infected women are married and monogamous. They are nonetheless shunned by their own families, left to fend for themselves, with no or few skills and very little training. So many of them are forced to sell themselves. This obviously is another way that the disease is spread.

Women are the key to the AIDS crisis in India. It seems to me obvious that the only real solution to this challenge is empowering women - through education, information, and finally guaranteeing their human and reproductive rights. You do not need to be a feminist or even a humanitarian to reach this conclusion. You just have to spend a little time in India.

As most of you are aware, India is an incredibly complicated, confusing place. I have rarely met so many strong, accomplished, powerful women as we did in India. And yet the vast majority is just the opposite. They are disenfranchised, and voiceless and powerless, married off much too young, uneducated and lacking status either in Indian society, or equally important, inside their marriages-- unable to demand that their husbands use condoms or make any other sexual demands. Violence is often the answer to such demands. And AIDS is the consequence of their powerlessness. This unequal situation is sadly not new. What is new of course is the presence of HIV, which has made this situation urgent.

We know from other places that if India does not take forceful measures now, while its HIV population is limited to 1%, but 1% of a billion is an awful lot of people, but if they don't take forceful measures now, HIV could reverse the great strides that India has made in recent years as a modernizing, strong nation. Left untended, AIDS could destroy that dream. We have seen in other places that leadership is the critical variable. We have seen the remarkable turnaround in Uganda, in Thailand, in Senegal, when leaders commit at the highest level and launch nation-wide campaigns - in effect declaring war on this killer. The problem has to be attacked by every sector: public, private, NGOs, the media, the corporate sector. Every sector has to attack from its own base. But above all what is needed is the political will and it has to be attacked now because though it is contained in India, it cannot stay contained.

What our trip to India made crystal clear to me is that India's top priority at this stage should be the destigmitization of AIDS. But given that AIDS has spread in India through sexual contact and only to a small degree through needle use, it is very tough to get Indians to talk about it, and yet they must. My husband and I met with the President of the country, Dr. Abdul Kalam, who told us that he was placing a great deal of faith in the development of an anti-HIV vaccine. When I mentioned to him that that vaccine, as far as I know, was possibly a decade away, he really didn't engage on what else India ought to be doing at this stage. So there is still this widespread feeling among those in positions of power in India that it's a rather small problem.

But no disease can be contained in the age of globalization. We saw how quickly SARS spread from a low-income housing project to paralyzing all of Hong Kong. But then it was contained because the Chinese leadership acted with great force and energy and brought it under control. That's what it takes.

AIDS spread to India most likely through South Africa, where there is a very large Indian population and as Adrienne already pointed out, workers move where the jobs are, leaving their wives behind and that is how this invisible disease is spread.So in India, prevention needs to be the focus. Treatment of the thousands already ill is also vital; I don't mean to underrate that. But without prevention, the situation will soon be catastrophic. And women must get special attention, as they are the most vulnerable population in India. They are also the core of the family so that when a mother is stricken, it is the entire family that implodes. My husband and I have traveled to 11 African countries that are at a far more advanced stage of AIDS and we have seen what happens to families when the mother is infected with HIV. And we have also seen what happens to economies when AIDS is left untreated. We have seen economies where for every job opening, two people have to be hired because of the certainty that one of them will succumb before too long, to HIV. Those economies are now in a state of collapse.

Women must also be given special attention because it is clear from these other places that we cannot rely on men to use condoms if women do not insist. A nation-wide, mass media education campaign about how to use condoms and their vital role in preventing the spread of AIDS should be started immediately. One hundred percent condom use in brothels, as is already the case in Thailand, for example, should be required.

Condom use of course is only a part of the prevention answer. We are of course all in favor of the A (abstinence), and the B (be faithful), to the C (condom use). But you need all three. You cannot put lives at risk on a policy that is based more on hope than reality and if you stress abstinence only, you are basing policy on hope.

HIV-infected women have to be treated with the compassion that they deserve. This, tragically, is far from the case in India today. They must not be shunned and they must not be forced to prostitution. This is the most self-destructive policy imaginable. Above all there must be a spirit of openness and honesty, which is a long way from being the present case. There simply is no time for traditional squeamishness and prudishness on the subject. It is far too late for that.

Drugs, anti-retroviral, are becoming more widely available and they make testing for HIV much more than a possible death sentence. They mean that people can live long and productive lives but they must first be tested and that will happen only if HIV is destigmitized. There is really no time to lose. India cannot retreat into wishful thinking that the disease will not spread.

Indian society will benefit in so many ways if women are finally allowed to be full and productive citizens. Skills training of these women is a low-cost, high-return measure. We visited community-based centers, Adrienne, Richard and I, where when we asked young women what they most wanted, they universally answered, jobs. We were also surprised how openly young men and women with us as mediators were willing to discuss subjects that we were led to believe were taboo, how they relate to each other and their knowledge of how AIDS has spread. It seems that their knowledge base does go beyond Bollywood films, where the hero never does kiss the heroine. Given the fundamental inequalities of Indian life, no group is more vulnerable to AIDS than young women. This is true in India and unfortunately it is true almost everywhere. The young women we met were impressive with their spirit and their resilience and their strength but they need information, they need knowledge and they need to know, and their future husbands need to know above all, that violence against them is not acceptable. They need to know that they have rights.

If as a result of HIV, Indian women, the most vulnerable, are finally empowered, accorded the human rights that have been withheld from those not lucky enough to have been born into the right caste, then something positive may yet emerge from this plague. You can only control the spread of AIDS by finally giving women their full rights inside their marriage and inside Indian society. There is no other way.

Thank you very much.

Ms. Germain: Thank you Kati. Now we will listen to the voices of women, directly, from Nepal, through a video created by the Margaret Sanger Center International.

From the Nepal video:
Announcer: Although Nepal is the only Hindu kingdom in the world, its population of 24 million people includes Hindus, Muslims and Buddhists, who contribute to its rich, multi-cultural life. Despite its breathtaking beauty, Nepal has suffered political instability and poverty that has taken a great toll, particularly on the lives of women. They are more likely to die in childbirth than in almost any other country in the entire world. More than 60% of women in Nepal cannot read or write. Most young girls are married by the age of 16 and less than one in three women will ever use contraceptives.

Until recently the legal status of women in Nepal was very low. Women had few legal rights in divorce and many women were imprisoned for having been suspected of having had an abortion.

But thanks to the tremendous efforts of women's organizations, the medical and legal communities, and government officials, the people of Nepal are making significant progress towards greater rights for women. In April 2002, the Nepal constitution, originally drafted in 1990, was amended to be more inclusive of women's rights. The Eleventh Amendment to the Constitution now provides enhanced property and inheritance rights, progressive divorce laws and stronger prosecution of rape crimes.

For the first time in its history, the Eleventh Amendment legalized abortion in Nepal.

To learn more from our colleagues in Nepal about their heroic efforts and current challenges, staff from Planned Parenthood of New York City spent two weeks in May 2003 working with the Family Planning Association of Nepal. This exchange visit was sponsored by Global Partners of Planned Parenthood Federation of America. On our visit we met many extraordinary women: advocates, government officials and ordinary women, who have come together to work for change. These are their voices.

First let us hear from Uma, a woman who directs a woman's micro-credit association that provides loans to women to start small businesses. Uma thought the women in the village couldn't make any decision or attend meetings to participate in any social change. Now her organization provides vital services to widows, young single mothers and girls, including economic development, health care and literacy. Hear her story.

(Voice with subtitles)

The doctors and ob/gyns have seen firsthand the suffering of women who have had self-induced abortion or who have gone to unskilled and unsafe providers out of fear and desperation. Dr. Suda Sharma is the president of the Nepal Society of Obstetricians and Gynecologists. She and others in the medical community have worked to change the harsh anti-abortion laws. Hear her story.

Dr. Sharma: We have seen many women who come to the hospital with complications of abortion. If I tell you what are these kinds of complications, you would be shocked because some of them range from making a hole in the womb, rupturing the uterus and pulling out intestines. Those are the kind of complications we have seen. And we have seen practically everything from cow dung to sticks being inserted inside the wombs of the women. And some of them have died; some have recovered with a lot of morbidity. So all of this made us think, me personally and all of us in our OB/GYN community, that we really need to do something about this and it is high time that this was a legal service provision in all the government hospitals so that women do not have to resort to this clandestine abortion and invite all these complications. Basically the state of the women is what prompted me to advocate and to plead for everything that happened.

Announcer: Women journalists are banding together to raise the media's awareness about the status of women in Nepal. Among these groups is Women Communicators, founded by Banda Narana, a journalist and Nepali TV anchorwoman, who intends to harness the power of the media to raise awareness among Nepali women and girls about their reproductive rights. Hear her story.

Ms. Narana: My mother and grandmother never thought of information as a power. They never thought that they needed information. The only information they got was what was told to them by their husbands, by their fathers, by their brothers. And they were never taught that they needed to acquire this information. But interestingly now there is a growing number of women who are interested in information technology.

Announcer: Sapna Malla, founder of the Forum of Women, Law and Development is particularly concerned with the impact of US policies such as the Global Gag Rule and the restrictions on funding for United Nations Population Fund, which has had a negative effect on Nepal's efforts to increase access to reproductive health services and safe and legal abortion procedures. Hear her story.

Ms Malla: I am a direct impact of what we have been seeing with Family Planning Association itself and even UNPF funds. Even though it is not direct funding, we have been affected. In a critical time like this in Nepal where abortion has been legalized and now we are in a situation where we need to have services. We really need support from all the countries that could provide technical as well as services. We also see reproductive health rights as one of the fundamental human rights of women and on one hand we see America as a model. We also think that when abortion is not illegal in America, how can the government introduce such policies, which have such a negative implication in the lives of women, in developing countries?

Announcer: The strength and commitment of these women is moving Nepal forward. US policy should not be holding them back. We must make their voices heard by the policy makers who can make a difference. You can do something to help. Write your senators and representatives and tell them you support unrestricted international family planning assistance. Tell them to fully fund the United Nations Population Fund. Tell them to end the Global Gag Rule. Inform yourself and your neighbors about international sexual and reproductive health and rights. Take action. Thank you for heeding the voices of the women of Nepal.

Adrienne Germain: Now we should move to Dr. Bista, who is a key actor in one of the most important NGOs in Nepal, working to serve girls and women.

Dr. Nirmal Bista: Good evening ladies and gentlemen. I am here to talk about the Global Gag Rule (GGR) and how it is affecting the health and lives of women in countries like Nepal. From the film just shown one can easily know about the poor status of women in Nepal in all fields.

The problem is even more serious in the case of the reproductive health of women and the exercise of reproductive rights. Our society is characterized by early marriage. Almost 40% of girls get married by the time they reach 17 years of age. According to a Kathmandu based study, about one third of women in the rural area and one fifth of women in urban areas experience unwanted pregnancies. And due to early marriage, there are a lot of teenage pregnancies, with serious implications.

About one third of women have unmet needs in contraception and another one-third never expressed a desire for contraception. Both together are at high risk of unwanted pregnancy.

Nepal is considered the country having one of the highest maternal mortality rates in the world.I would like to share this figure: that 2,675 women become pregnant everyday, 991 women face unwanted pregnancies and 399 get pregnancy related direct risk. And it is heart breaking to know that everyday, 13 maternal deaths take place. A significant proportion of these maternal deaths are due to unsafe abortion. In the past women were sent to jail for having an abortion. Therefore the organizations like us, working in the field of reproductive rights and reproductive health, the major concern for us was the elimination of unwanted pregnancies and prevention of unsafe abortion.

Fortunately we came to the point in September 26, 2002, when both houses of Parliament approved the 11th amendment to the Civil Code Act which has liberalized the law relating to abortion and also provided the right to women to inherit property. That is a significant turning point in the history of Nepal. We popularly call it the 11th Amendment. We are not only talking about the high maternal mortality and how the liberalized abortion law can lower the maternal mortality rate. We also have to look at the high incidence of health-related morbidity, which affects the women, which affects the family, which affects the children.

Family Planning Association of Nepal, FPAN for short, is a leading non-government organization in the reproductive health and family planning field for 44 years and it contributes to one-third of the family planning services in the entire country.

In 2001, we had a very difficult situation, when we were asked by our American friends, that either we sign the provision that is in the Global Gag Rule and abide by the restrictions. Or we were to be denied the support or the partnership, which we have had for almost 25 years. And it was a very difficult decision and very painful decision for the non-governmental organization like Family Planning Association to just say no to the Global Gag Rule and to refuse US money in exchange for signing the provision. One of the very surprising things about the GGR is that it does not affect the government. It only affects non-governmental organizations outside the United States of America. Those non-governmental organizations, if they are to receive US federal funds, cannot advocate or promote abortion or abortion-related activities, even with their own non-US money. That is very much a double standard in the GGR.

With the result of this GGR, a poor non-governmental organization like mine lost about $600,000 per annum, that is program funding plus contraceptives like condoms. You can imagine the proportion of that money to an organization like mine, which has a core budget of only $1 million.

This has substantially reduced or degraded our capacity to provide basic reproductive health services like antenatal care, like post-natal care, immunizations, basic care for newborns. Those services were also affected adversely.

We had to lay off about 200 trained services providers including management staff and in some facilities, the position of full time doctor had to be replaced by part time doctor, affecting the quality of care. While working with youth and adolescents, we have quite a successful experience in reaching the youth in terms of providing reproductive health and information to them and also preventing them from having STI and HIV/AIDS. We have Youth Information Centers in different parts of the country. And we have found it to be a very effective vehicle to reach youth. In 2001, when that rule was in place, we had planned to have an additional 30 outlets. But due to the cut, we had to restrict (our growth) to half of that. This way we had to downscale our activities relating to youth, gender, women's empowerment and also prevention of HIV/AIDS. And as our previous speaker has pointed out about the HIV/AIDS situation in India, we share a long, unregulated border with India and people come and go freely. That means we are very near the HIV/AIDS epi-center. With the fund cut, our activities addressed to HIV/AIDS are also adversely affected.

I have come to the point as to why FPAN did not sign the GGR. Because for us, it is a matter of principal for an organization working for last 44 years and always championing the cause of women's rights, women's health and taking the lead role in doing advocacy for liberalization of abortion law for 23 years. It was a matter of principal and that is why we did not sign. By complying with the GGR, we cannot work with government, NGOs, INGOs, health professional who have reached a consensus that decriminalization of abortion will reduce maternal mortality rates in Nepal. Fortunately now the law is liberalized. Had we signed the Global Gag Rule we could not have, together with the government and other NGOs, (worked) for the provisioning of services and advocating to eliminate unsafe abortion in Nepal. As the pioneer nongovernmental organization, our view on the Global Gaga Rule is it will definitely increase unwanted pregnancies and therefore more abortion and in many rural areas more unsafe abortion and then more maternal deaths. It will jeopardize the effort to combat the HIV/AIDS pandemic. Though it is meant to limit abortion, in practice it is affecting the whole range of reproductive health services, denying the services to those who need it most. And of course it is against the fundamental right of a woman to make decisions about herself and her body.

Ladies and gentlemen, I would like to request all of you to speak, to write and to take a step against this destructive policy that is affecting the health and life of developing countries like mine. Thank you very much.

Ms. Germain: Thank you very much Dr. Bista. Now I will introduce Lucy Atkins, who is the Director of the Margaret Sanger Center International for our final comment.

Lucy Atkins: Inspiring presentations we have heard tonight speak to us of two opposing forces: on the one hand we heard about the slow but inexorable progress being made throughout the world towards women's empowerment and freedom of choice; on the other hand we hear and see the dramatic crusade being waged by the ultraconservative opposition against that very same progress. In many cases, such as India, this opposition arises from traditional patriarchal culture, laws and practices. Many of the customs there probably seem foreign to most of us in this room. But ironically, we, as citizens of the world's most developed nation, need to realize that our own government, the most fundamentally religious government we have ever had, has joined the battle -- and in some cases is leading the charge -- against women's empowerment.

My message tonight is simple: we are in the midst of a major cultural struggle between two very different world visions. This is not just a political disagreement on any specific policy or piece of legislation. This is a battle between two very different ways of viewing the world. And at the root of this conflict lie opposing views on women, power and sexuality. That's right: women, power and sexuality.

We at Margaret Sanger Center International have a vision of a world where healthy sexuality, reproductive choice and gender equity are accepted parts of life. I believe most of us in this room share this vision. Our vision is of a world where:

• every child - whether a girl or a boy - is born wanted and equally valued
• where children and young people are encouraged to learn all they need to know about their sexuality and reproduction; and
• where individuals and couples can exercise their human right to freely decide how many children they will have. But also our vision is about a world:
• where every person can chose - without coercion or fear -- with whom, when and how to have sexual relations
• and where sexuality is embraced as an essential, pleasurable, health- and love-promoting part of life.

However, the ultraconservative, religious opposition does not share this vision. On both sides we believe fervently in the honor and goodness of our visions, however we disagree totally on issues around women, power and sexuality. The religious extremist opposition in this country - the Evangelical Christians who accounted for 40% of the President's vote and who increasingly control domestic and foreign policy -do not share our vision of the world we are working towards. In their vision, the "natural family" is dominated by the male and women dedicate themselves to raising all the children that come their way. Sex is only to take place within the confines of heterosexual marriage for purposes of procreation. Indeed, in their worldview, sexuality and particularly women's sexuality, is the root of man's downfall. It must be controlled, so that women remain subordinate to men. It is only by understanding this opposing world view that any sense can be made of the kinds of policies that the current Administration has been pursuing in relation to family planning, reproductive rights, HIV/AIDS and sex education.

These policies are consistent with their worldview and they are intended to be imposed throughout the world and here at home. Make no mistake about this; policies we are seeing imposed overseas, that are affecting the women of India and Nepal, are policies that this Administration intends to apply in the United States as well.In our video, Sapna Malla was incredulous about how the US government could apply the GGR abroad when abortion is legal in the US. What she didn't know is that this Administration is also upset about that inconsistency: it intends to make abortion illegal in the US, too.

We heard from Nirmal Bista about the devastating effects of the Global Gag Rule. What Dr Bista told us is happening in Nepal is happening around the world. It is happening also in Zambia, a southern African country plagued by excruciating poverty and staggering rates of HIV/AIDS. At Margaret Sanger Center International we have been working for years with Planned Parenthood of Zambia to help build up their youth-friendly services and support their pioneering collaboration with faith-based and governmental agencies. Despite their ideological differences, religious and secular agencies in Zambia have joined forces, since -- in their words -- "the future of Zambia depends on the sexual health of its youth. Youth need to have access to accurate information so they themselves can choose the path that will help them stay alive." But now Planned Parenthood Association of Zambia, just like FPAN, is struggling to survive because it stood up for its principles; because it stood up for women. It too has lost major funding, has had to cut back on vital services, has lost access to condoms and other contraceptives, and can no longer provide life-saving services to youth. This is how the US is exporting its conservative agenda - designed to keep women subordinate, and youth ignorant about their sexuality.

Another area in which the religious conservatives are implementing their agenda is at the expense of people dying from AIDS. Although the President is undoubtedly moved by the tragedy of millions of people dying in Africa and the Caribbean, his ultraconservative agenda leads him to export an abstinence-only approach to HIV prevention. Again ideology takes the place of facts and good sense. How can the women we heard about in India "just say no"? How can the United States be a country that is telling the world to deprive its children of life-saving information?

Again it comes down to our different world visions related to women, power and sexuality. Margaret Sanger Center International's work to scale up HIV prevention programs around the world has shown that helping young girls gain power and control over their lives plus honest, down-to-earth sex education, are among the critical components of any successful HIV prevention program. But the Administration promotes abstinence-only. Actually abstinence is fine as a voluntary option but as an exclusive family planning method it needs to be reconsidered due to its extremely high rates of user failure and potential negative side effects. Remember, it has been said that the vow of abstinence is broken more often than latex condoms! The Administration's unrealistic focus on abstinence will only lead to more unnecessary deaths - but serves to promote the ultraconservative agenda.

And we also heard about the administration's refusal to provide support to the United Nations Population Fund UNFPA. The smoke screen is China's coercive one child policy. But this is not the issue since we all agree that coercion in family planning is never acceptable.

The reality is that UNFPA provides essential reproductive health services that are anathema to the ultraconservatives. These same services are the lifeblood of family planning, HIV prevention and sex education programs around the world. They are programs that help empower women - that help women gain a say in their communities, control the number of children they bring into this world, and prevent domestic violence …programs that help women control their lives. Precisely what the ultraconservatives do not want to happen.

So this brings me back to where I began: women, power and sexuality. Only by understanding that the ultraconservative agenda opposes women's empowerment, and needs to control women's reproductive and sexual freedom, can we understand what is at stake.

And it is precisely because so much is at stake that we all must take action now…and take action again …and again…and again. I urge you to support the groups you heard from here tonight: International Women's Health Coalition, Family Planning Association of Nepal and of course Planned Parenthood of New York City and its international arm, Margaret Sanger Center International. Visit us online at www.ppnyc.org to stay informed and take action through our on-line activist network.

Let your elected representatives know that you share our vision for the world we want to live in. Thank you.

Adrienne Germain: Thank you Lucy and thanks to all of you for your very compelling remarks. I think everyone here has voted with hands, so to speak. I hope we can have at least 20 minutes of questions and comments from all of you.

Before I open the floor entirely, I would like to thank one special guest for being here and for her very stalwart support for all of us and for women around the world: that is Jane Fonda, who is one of the most dedicated advocates for women's and girls health and rights that I know. So I thought perhaps Jane, you might be the first one to start off our discussion.

Jane Fonda: Thank you. I want to thank all of you for the most amazing, inspiring, motivational, disturbing presentations. They were very very powerful. I hope every one of us can get at least twenty new friends registered to vote and make sure they get to the polls. I mean, we need a revolution. Regime change.

As you know, I work with adolescent girls and boys in my state of Georgia, and have worked with the International Women's Health Coalition and especially in Nigeria. I would like to know whether child brides-how extensive child brides, child marriage is in South Asia and how you view that as a problem in regards to AIDS and what to do about it.

Dr. Bista: Actually, marriage at a very early age is quite common, in Nepal, India and Bangladesh also. And when a young girl is married who doesn't know anything about her body and her body is not developed and even her partner' behavior, maybe, is not according to the need or the medically permitted thing. They do not know, because there is less information, less access to services, in that case, if they are infected by any STI or any other diseases, there is the chance that it will transmit and it will spread.

Ms. Germain: Perhaps to add to that, after so many years of work in Bangladesh, we are seeing the age of marriage go up. By investing in girls at a young age, supporting and encouraging their families to allow them to go to school, there are so many different strategies that we all now know about and that have been tried on a small scale but that really need to be increased and enhanced a great deal.

One of the most stunning memories I have from this most recent trip to India with Kati, it occurred actually after she left, I was with a bunch of girls again in the same area of Delhi that we had visited together and there were some very young ones there. And ultimately after we were having all this conversation and lots of laughter about marriage and engagement and sex and whatever, I finally decided I would ask how old this very small girl was, who had been quite talkative and all. She was 12. The other girls told me she had been already engaged to be married. So I asked her, did she know her husband? And she said, yes, I do. I said, well, do you like him? And she said, well, you know, I don't really know yet. But the girls around her gave her such sustained support. It was so clear to me that there was nothing this little girl could do about it. She is engaged and she will be married as soon as she menstruates.

But she had the support and the strength of those girls and through this program, she had also begun to learn about her body, about menstruation, and when she goes into this marriage, at least, as Dr. Bista was saying, she won't be like so many millions of others, who go into a marriage as a child, who know nothing and often are married to a much older man. So there are programs that do reach out and that's what we need to do: to support young people, as Kati was saying and as Lucy and all of us have said, regardless of the fact there are those who say well, we can't do that, it's culturally sensitive, or what have you. It can be done. I think we should move to other questions and concerns from the floor.

Question: I am a returned Peace Corp volunteer from the Philippines and am currently studying to be a midwife at Columbia University and hope to work internationally with some kind of organization like one of these. My question is twofold: having been in the Philippines, I spent a lot of time working with women who were either formerly prostitutes or currently prostitutes. Part of the problem was the influx of foreigners coming in and the lack of control they had in dealing with those foreigners. And again, the prostitutes could be 12 years old. The other problem was the health aspect of it: they were not properly screened, and although the government tried to screen, they could easily pay off the health officials who screened them so that the number of reported cases of HIV/AIDS is much less than it is in actuality. I am wondering in South Asia, India and Nepal, whether it is like that as well.

Ms. Marton: Well, I am afraid it is very similar in India. I think Thailand is the role model for what we are hoping will be the next stage for India as pressure begins to mount on the government to apply some sort of central control over brothels, which clearly needs to be done, not only enforcing condom use but also testing the sex workers. But India is such an enormously disparate and multi-layered country, where the states really are almost semi-autonomous, it is very difficult for central control. That is why I was emphasizing the need for pressure to be applied from every quarter.

One of the things we did while we were there is we participated in a conference organized by Indian corporations and they are now stepping up to the challenge of doing what the government is clearly not doing because they realize that so much is at stake for India's economy. So there really is room for hope there because they seem to be stirring from their slumber. And as you mentioned, the sex workers are very important and they are a fact of Indian life, an unavoidable and inescapable fact and they are an extraordinarily dangerous fact. The only way to go is to have some sort of regulation there. Adrienne, you may want to say a few words about your experience with sex workers in Calcutta.

Ms. Germain: Yes, one of the things about India is that whatever one might hope to find in the world, one can find there. I spent the most amazing day with unionized sex workers in Calcutta. We don't have time tonight to tell their entire story but they organized themselves, and they did it for three reasons. One was to ensure that all of them would use condoms, would demand their clients did, because if not all sex workers in a district demand it, the clients will just go to the ones that don't demand condom use.

Point number two was that Calcutta being very close to the Bangladesh border, they saw over the years a lot of girls and young women trafficked from Bangladesh and also sometimes Nepal into Calcutta and they think that is wrong, not just because of the age of the girls but because it is trafficking. They are brought under false pretenses. And they have it all divided up into districts, you know, West Bengal has been run by a Communist party for a long time, so they know how to organize. And they have organized all the sex workers in the entire state and I don't usually make such bald comments, but in this case there is a very strong research element attached so we do know that that organizing and that strength means that in the years since 1992 when they were first tracking prevalence in that community, HIV/AIDS was at 2.7% among sex workers in Calcutta. Today the rate of HIV/AIDS infection is less than 5%. In Bombay, in the very infamous districts there, where so many of the girls from Nepal are trafficked, the rate of infection among sex workers is 80%.

Now the group in Calcutta has had support to reach out to whatever groups of sex workers they could find in six other cities. That support is coming to an end and while I visited there, they asked me what we could do about this because the government of India which has to clear any non-governmental group receiving foreign funds is sitting on the approved grant from the outside donor, they are not forwarding the file. Meanwhile the members of the union from Calcutta have not been able to reach out to their group in Bangalore, which was just starting up.

To connect back to Kati's comment about the corporate world, one of the ideas that we have, which would be very hard for corporations to take on, but they are big corporations in Calcutta, one of our ideas is that the local Indian corporations should finance the unionized sex workers of Calcutta to reach out to those sex workers in other cities and help them mobilize in the same way. Then they can avoid the government problem with foreign money and go ahead and do their own thing.

Ms. Atkins: I just want to say that by these comments, you can tell that in HIV prevention work, it is essential to be able to work with prostitutes and to work in different ways around issues of trafficking. One of the difficulties again with US policy has been that on the HIV bill that is being still considered, they have added a provision that says any agency that receives HIV funds has to make a statement that it is in opposition to prostitution and trafficking. And so you can't then work with the people, like the unionized prostitutes that you might need to be working with. So this is again another piece of tension within the legislative environment.

Dr. Bista: We have had a very good experience in addressing HIV/AIDS in Thailand. The situation in South Asia is a little bit different in the sense that in Thailand the society has allowed the government to accept the fact and just geared all the reports towards the problem. But in the case of South Asia, Nepal or India, it is the denial on the part of society and also from the policy makers in the government that is creating a hurdle in addressing this enormous problem. Now, gradually with HIV/AIDS in a pandemic situation, now the policy makers and government people are also starting to speak along that line. But still there needs to be a lot of non-governmental organizations and social activists to accept the situation, to accept the problem.

Question: I spent some time working in a social marketing program in Ethiopia and I think perhaps due to the nature of social marketing, they are forced to separate anti-AIDS or AIDS education and family planning education and focused on condoms as a method to prevent the spread of AIDS and other sorts of family planning, birth control from the family planning aspect. I was wondering if you see separating these two as counter-productive and perhaps giving a conflicting message to the women you are supposed to be educating?

Ms. Atkins: This is an issue that has been around for quite a while. I know in Cairo in 1994, the effort was to try to say that all of reproductive health and HIV prevention services have to be integrated. And there is a long tradition of trying to promote greater integration of those services. Ironically under the Global Gag Rule, there has been a difficulty in that population funds that are gagged, if they touch HIV funds, if they are brought together in a project with HIV funds, then the HIV funds become gagged also. And so it is sort of the height of irony that we have worked for so many years to say that these kinds of services have to be integrated and now we are in an environment that just because of the funding sources, they can't even touch each other.

Ms. Germain: We could give many examples of this kind of problem but one thing I would mention in a way that is sort of special to South Asia is that all of these countries have had national family planning population programs, since the early 1950s in the case of India and shortly thereafter for the other countries. And those programs were so intent on demographic objectives that actually condoms came way down the list of family planning methods that were provided in those programs. In fact, sometimes even family planning workers would say well they are not really very effective, have an IUD instead.

So one of the special challenges we face in South Asia now is to build up the understanding of what condoms are, how to use them, how important it is, both for family planning and for prevention of not only HIV but other sexually transmitted diseases. But meanwhile one of the most powerful comments Kati and I heard while we were in India, which I was so glad that I wasn't initiating that comment at that moment, is that if we need any technology at all, the technology we most need and must have is something called microbicides, which would be like a jelly or a foam that women would use that would protect both them and their partner against HIV/AIDS. So there is a lot of work to be done. Condoms are what we have now, so we need to promote them, destigmitize them, laugh about them over the dinner table, whatever. But we also need and the US government funding for this is critically important, is a much greater investment in the development of a technology that women truly themselves would have control over, with or without her partner's knowledge.

Question: As I hear these conversations, I feel so inspired and again, so troubled. My question is, I support the idea of women empowering women, empowering girls, knowledge. I also feel the real ache and need for what's being done on the other side of the handshake - the boys, the men. I would love anyone to respond.

Ms. Marton: Thank you for raising that because of course, both have to be dealt with. And changing behavior patterns takes much longer than condom distribution or hopefully microbicides. To change how people actually relate to each other is tough work. But in fact we have been involved in Nigeria in a successful program of young male behavior modification and there are instances of it all over the developing world. But no, I don't think we want to give up on male behavior. We want to encourage its modification, the other side of the handshake.

And I must say that the adolescents that we met with in India seemed to be of a more progressive bent so I think it is yet another more positive byproduct of globalization. Nothing can be isolated, diseases, what have you, but different behavior patterns are also exposed as a result of globalization and mass media and women are seeing that there are other options and are putting more pressure on their male partners for modification.

Ms. Atkin: Yes, when we talk about gender equity promotion, we are really talking about both work with girls and boys, women and men. Two years ago I remember going to a meeting in Washington, talking about trying to promote male involvement. Margaret Sanger Center International has been working in men's programs for probably a decade but it's gotten very much more popular now. There was a committee in Washington that was trying to find examples of programs that were working with boys and men, particularly from a gender equity promotion focus and there really weren't that many.

And I just went to a conference a month ago and we had to have simultaneous sessions. It was an international conference and there were 300 presenters from all over the world, with different arrays and different kinds of programs but I think the idea has caught on that while we are talking about women's empowerment, men and boys have got to change and have got to benefit from the change in gender roles. Traditional male gender roles are killing boys and men by HIV/AIDS, in violence and homicides and alcoholism. Once you start working from a gender equity perspective, men and boys, particularly boys and adolescents, really see the benefit of redefining some of those patterns that have driven them to some very life-threatening behaviors.

Ms. Germain: We can end on that note and reiterate and reinforce that we do face a win-win opportunity here. Investing in girls and women is good in its own right and in its own sake. It also, whether in South Asia or worldwide, will help countries make the progress they want. I hope now you will join us for a brief reception and more of your questions and concerns can be raised directly with the panelists. Again, thank you so much for coming.