By Sharanya Sekaram

Image Credit: UNFPA

In 1994 O.J. Simpson was arrested and charged with the murder of his ex-wife Nicole Brown Simpson and Ronald Goldman, Kurt Cobain passed away, the Rwandan genocide took place and Nelson Mandela became the President of South Africa. In Sri Lanka Prime Minister Chandrika Kumaratunga won the Presidential election that followed the assassination of President R. Premadasa, and several prominent hardliner UNP members are killed including Gamini Dissanayake.

Alongside these politically defining events, in September 1994 the International Conference on Population and Development (ICPD) took place in Egypt, Cairo. Some 20,000 delegates from various governments, UN agencies, NGOs, and the media gathered – including the Government of Sri Lanka and the resulting document – the Programme of Action is the steering document for the United Nations Population Fund (UNFPA) to-date. The UNFPA website describes ICPD as follows:

“Today, it is globally recognized that fulfilling the rights of women and girls is central to development. But if one were to trace the origins of this realization, many threads would lead back to Cairo in 1994. There, at the International Conference on Population and Development, diverse views on human rights, population, sexual and reproductive health, gender equality and sustainable development merged into a remarkable global consensus that placed individual dignity and human rights, including the right to plan one’s family, at the very heart of development”

The conference delegates achieved consensus on the following four qualitative and quantitative goals through their Program of Action:

1. Universal education: Universal primary education in all countries by 2015. Urge countries to provide wider access to women for secondary and higher-level education as well as vocational and technical training.
2. Reduction of infant and child mortality: Countries should strive to reduce infant and under-5 child mortality rates by one-third or to 50–70 deaths per 1000 by the year 2000. By 2015 all countries should aim to achieve a rate below 35 per 1,000 live births and under-five mortality rate below 45 per 1,000.
3. Reduction of maternal mortality: A reduction by 1/2 the 1990 levels by 2000 and 1/2 of that by 2015. Disparities in maternal mortality within countries and between geographical regions, socio-economic and ethnic groups should be narrowed.
4. Access to reproductive and sexual health services including family planning: Family-planning counseling, pre-natal care, safe delivery and post-natal care, prevention and appropriate treatment of infertility, prevention of abortion and the management of the consequences of abortion, treatment of reproductive tract infections, sexually transmitted diseases and other reproductive health conditions; and education, counseling, as appropriate, on human sexuality, reproductive health and responsible parenthood. Services regarding HIV/AIDS, breast cancer, infertility, and delivery should be made available. Active discouragement of female genital mutilation (FGM)

Through this document – countries, including Sri Lanka, made bold commitments to transform the world by ending all maternal deaths, unmet need for family planning and gender-based violence and harmful practices against women and girls by 2030. Today, “ICPD” is often used as a shorthand to refer to the global consensus that reproductive health and rights are human rights, that these are a precondition for women’s empowerment, and that women’s equality is a precondition for securing the well-being and prosperity of all people.

A quarter of a century later, and just a decade away from the timeline set out, where is Sri Lanka really in the promises made?

Global Impact of ICPD

There is no doubt that 25 years later ICPD has become an acronym embedded in the discussion around sexual and reproductive health and rights and continues to be viewed as a watershed moment for several movements. It has defined and shaped policies around population issues globally including immigration, infant mortality, birth control, family planning, the education of women, and protection for women from unsafe abortion services.

The UNFPA website states,

“A quarter of a century later, the world has seen remarkable progress. There has been a 25 per cent increase in global contraceptive prevalence rate around the world. Adolescent births have declined steeply, and the global maternal mortality ratio has fallen. But progress has been slow and uneven. Hundreds of millions of women around the world are still not using modern contraceptives to prevent unwanted pregnancies, and global targets on reducing maternal deaths have not been met”

Perhaps one of the most prominent markers of the ICPD is that it brought the global community together and established that the rights and dignity of individuals, rather than numerical population targets, were the best way for individuals to realize their own fertility goals, opening the space for these issues being seen as more than something that affects a subset of the population, but rights that are essential for global development. According to UNFPA voluntary access to modern contraception has increased by 25%, and preventable maternal deaths have fallen by 40% which are vital markers in uplifting the quality of lives of women and girls. A report published by The United Nations on ICPD progress in the Asia-Pacific says “The report reveals that the Asia-Pacific region can be proud of many successes in the last 20 years in the implementation of the Programme of Action, including increased life expectancies, reduced fertility rates, and better access to, and knowledge about sexual and reproductive health services”

It seems however that the “R” for Rights in Sexual and Reproductive Health and Rights remains elusive in the approaches of both several INGO’s and governments. Rooted in a public health angle that remains trapped within gender binaries and norms, we often see approaches being framed within the patriarchal heteronormative idea of what a family is and looks like. A rights-based approach than centers the human rights and dignity of people accessing services regardless of the perceived morality of their circumstances and choices evades us constantly. This results in those who are the most marginalized and need these services the most falling by the wayside – including people who identify as queer, persons with disabilities, people who identify as transgender and sex workers.

This has not gone unnoticed or unspoken about – for example the Framework on Rights of Sex Workers & CEDAW which was developed by International Women’s Rights Action Watch Asia Pacific in partnership with the Global Network of Sex Work Projects reminds us “ Sex workers across the world face acute human rights violations that occur in a variety of social, economic, political and legal contexts. Discriminated against by law and often socially stigmatized and marginalized, sex workers confront abuse in the context of health and social care, housing, employment, and education, often perpetrated by police and other state actors”

The chances of you accessing these rights operates on a sliding scale for those who’s identity lies in the intersections including queer people with disabilities or transgender sex workers. Do we really think of sex workers as mothers or transgender men needing access to gynecologists? The answer is usually no.

What Progress for Sri Lanka?

It would be unfair and incorrect to assume off the bat that in the last 25 years Sri Lanka has taken no steps forward in the commitments made at ICPD. To the contrary there have been some important successes that have been key in making Sri Lanka one of the leaders in the South Asian region with regard to these issues. This is particularly in the areas of universal access to education, maternal mortality and infant mortality.

Sri Lanka has a low HIV prevalence rate particularly when compared to the region and offers testing and treatment free at dedicated STI clinics supported by the public healthcare system. Family planning options and maternal health care has been effectively integrated and mainstreamed into the existing health care system allowing for an excellent reach into even the most rural areas. This has been done through mechanisms such as the Family Health Bureau.

The Family Health Bureau (FHB) is the focal point for Maternal and Child Health (MCH) in Sri Lanka. FHB was established in 1968 within the Ministry of Health to implement the MCH programme throughout the island. This was initially designated as the Maternal and Child Health Bureau and was later re-designated as the Family Health Bureau. Maternal health, child health women’s health and family planning form main components of the family health programme of Ministry of Health, Sri Lanka. The services are provided through the carefully streamlined infrastructure of the Ministry of Health and Provincial Health Services which comprise wide network of medical institutions and Medical officers of Health (MOH) areas. Sri Lanka has created dedicated ministries responsible for the deployment of migrant workers and for fostering relations with their national diaspora responding to the question on the rights and protection of migrant workers raised repeatedly at ICPD.

In March 2018, the NSACP hosted a media seminar at which they discussed their moves to eliminate mother to child transmission of HIV and Syphilis and in September the WHO accreditation was awaded sanctioning this. Dr. Lilani Rajapaksa, National Coordinator, of the ‘Project to Prevent Transmission of HIV and Syphilis from Mother to Child’ told the seminar conducted at the Health Promotion Bureau yesterday that the number of HIV/AIDS infected persons stood at 3,195 at the end of 2018 and Syphilis and Gonorrhea patients countrywide stood at 100. “The spread of the three diseases in Sri Lanka is about .02% a year and this is one of the lowest in the region,” Dr. Rajapaksa said. “Our ambition is to make the future generation free of HIV and syphilis infections. Sri Lanka is planning to obtain validation certificate by the World Health Organization (WHO) as a country which has “eliminated mother to child transmission of HIV and syphilis.”

Research from the International AIDS Society (IAS) Conference 2017 shows that those on effective treatment do not pass on the virus. Also in 2017, The Terrence Higgins Trust (UK) also began their can’t pass it on campaign that states: “Scientific evidence shows that people on effective treatment for HIV are not infectious. This is because the treatment will reduce the amount of the virus in their blood to such a low level that it is no longer able to infect someone via the usual routes. That’s a really important and remarkable thing for a number of reasons. First of all, it means there should be no new HIV infections. We can stop HIV being passed on by encouraging people to get tested and treated.

Sri Lanka would be well served on focusing on their Test Treat goal to achieve their 2025 vision of ZERO New HIV Infections and ZERO AIDS Related Deaths. The only people who remain infectious are those who don’t know their status and those who aren’t on treatment. This is desperately needed especially in the context of continued misinformation such as this article published on the Daily News earlier this month:

Subha Wijesiriwardena (Women and Media Collective) speaking to Bakamoono.lk emphasized the need to acknowledge health professionals and women’s rights activists who have fought and continue to do so in bringing a holistic rights-based approach to these issues, often fighting long and sustained battles to ensure these successes are possible. She also noted the determined efforts made to include people of diverse sexual orientations and gender identities, particularly transgender people, even when the environment was less than welcoming.

Nairobi Summit 2019 and the March Forward

In November 2019, governments, advocates, health organizations, women’s and youth activists and others gathered in Kenya for the Nairobi Summit.  Here according to UNFPA, the goal was to “seek clear commitments that will advance the goals of the ICPD and secure the rights and dignity of all”. The summit was also in the context of the 25 years that have passed since commitments made at ICPD and the generations since to assess how we move forward.

IPPF Director General Dr Alvaro Bermejo told global and national leaders gathered to mark 25 years since the landmark International Conference on Population and Development (ICPD) that all participants at the Summit needed to recommit to transforming the lives of women and girls He said: “179 national governments signed up to the ICPD Programme of Action in Cairo 25 years ago. But signing is one thing, implementing another. It’s still about translating commitments on paper into action; action to transform the lives of women and girls and marginalised groups. This has to be a priority. This Summit is needed because although Cairo was a monumental achievement, the years since have not fulfilled its promise”

Wijesiriwardena attended the Summit as a member of Civil Society and reflected for Bakamoono.lk on what some of the overarching conversations and discussions that happened. She noted that what was perhaps deeply concerning was the threat of how “well organized and well resourced” anti-women’s rights, queer rights and SRHR movements have become globally – understanding all too well how to localize their action and simultaneously have a global reach – which was a context that did not exist in the same way 25 years ago. This results in those working to advance these goals having to be more strategic and consciousness of these campaigners who are not random in nature but targeted and well prepared. Specifically speaking about the Sri Lankan context, Wijesiriwardena highlighted the complete lack of progress and in fact continued push back against the decriminalization of and safe access to abortion as one of the biggest failings.

Sri Lanka has one of the most restrictive laws on abortion in the world and particularly in the region, only allowing termination of pregnancy in the circumstance that the mother’s life is in danger as per Section 303 of the Penal Code of 1883. The penalty for “causing a woman to miscarry (with or without her consent)” is up to three years’ imprisonment and/or a fine. Despite this, however, the Ministry of Health reported in 2016 that 658 abortions are carried out daily. Research carried out in two abortion clinics in Colombo in 1997 showed that more than 90% of patients were married women, and more than half of them already had one or two children. Among the reasons given by married women for needing an abortion were those of poverty and foreign employment. The debate around access and the right to choose to terminate an unwanted pregnancy has many faces and facets – from the very basic tenants of a woman’s right over her body to what it means for rape victims, victims of incest, and how we value the lives of women and girls in painful circumstances.

In 2017 debate sparked up around the recommendations made following the findings of the Justice Aluvihare Special Committee which are:

• To decriminalize abortion and allow for medical termination of pregnancies in the specific circumstances of: Rape and incest; The pregnancy occurring in a girl below the age of 16 (a victim of statutory rape); Serious fetal impairment
• To provide for a procedure for medical termination of pregnancies on one of the above grounds that will be rigorously regulated to prevent the abuse of the process
• To enact/amend legislation as appropriate to facilitate the inclusion of the above provisions.

The conversation was largely driven to public attention by mainstream media following a press conference held by the Sri Lanka College of Obstetricians and Gynecologists (SLCOG) in August 2017. The backlash from religious bodies – particularly the Catholic Church – was swift and any possible legal amendments were stopped before they could even begin. From that point to now – the situation remains unchanged.

It is also important to note that, one aspect that remains woefully undiscussed is the class and socio-economic aspect of this conversation. In the limited work that has been done by academics, the link between ease of access to termination and reasons women (often taking desperate measures) terminate against the law can be linked to broader health and socio-economic inequalities. Class inequalities do not exist in a vacuum and while the moral aspect of this debate is the loudest, it more often than not completely dismisses these very real structural inequalities that impact this decision.

Wijesiriwardena also discussed the continued heteronormative framing around marriage and sexual relationships which continue to leave people behind in how services and rights are accessed. The Family Health Bureau in its website for example describes a family as “Family Units with a married female at the age of between 15-49 or with a child less 5 years of age” as the demographic they focus on. This has many far reaching consequences – one of which is how the myth of virginity continues to flourish and thrive even in 2019. Advertisements openly offering ‘Virginity Repair’ that will allow people to to ‘Re-Discover Innocence’ in Sri Lanka are common and Bakamoono has written about this on previous occasions.

Promises, Promises, and More Promises

At the Nairobi Summit, Sri Lanka presented its country commitment via Dr. Chithramalee De Silva, Director (Mental and Child Health) of the Family Health Bureau, Ministry of Health, Nutrition, and Indigenous Medicine, Sri Lanka.

Commitments stated included; “reduce our maternal mortality ratio to the SDG goal of 20 per 100,000 LB by 2030” highlighting that “unmet need for family planning accounts for 20% of maternal deaths” and specifically referencing “making safe commodities available across the country”. The commitments also included the phrase “New legal enactments will be made available to ensure Reproductive Health rights are protected in all ethnic groups, socially disadvantaged populations, adolescents and youth”. In the context that the 15% of maternal mortality deaths is a result of unsafe abortions, access to safe and legal abortion is a recognized reproductive health right that very much affects “socially disadvantaged populations” disproportionately – what does this really mean? The vagueness of the statement suggests an evasion of really nailing down what the gaps in these areas are, which must be specified and spelled out in order to be successful.

It was heartening to hear the commitment that “Sexual and reproductive health education in schools, and adolescent and youth friendly health services will be further strengthened with the partnership of Ministry of Health, Education, Vocational Training and Youth Affairs” and we strongly recommend the National Institute of Education who is responsible for the development of syllabus’s and teacher training will be brought into these efforts as an equal partner. It is vital that curriculum and trainings in this regard use the comprehensive sexuality and relationship education guidelines developed by UNESCO that can be easily accessed. This must come from an age-appropriate, fact-based, scientifically accurate and realistic foundation that is not rooted in judgment shame or arbitrary decisions on what is “culturally relevant”. Failure to do so will mean in 25 years we will be continuing to repeated ourselves in this exact same way and young people will continue to be at risk.

We also welcome the commitment that “Primary Health care will be further strengthened for elimination of Gender based violence while care provision for survivors will be expanded through Mithuru Piyasa Centres”. We encourage the mainstreaming of existing services such as the Women and Children’s Bureau of the Police as they are often the first point of contact for victims of gender based and intimate partner violence. Sri Lanka in its work on maternal and infant health has already seen first-hand the success that comes from strengthening existing mechanisms and services as opposed to reinventing the wheel and we hope that learning will be replicated here.

We also noted with some confusion and concern the statement that Sri Lanka is  “progressing towards elimination of mother to child transmission of HIV and Syphilis with strong partnership of the Government, development partners and key population groups” – as mentioned before the National STI and AIDS control program has already announced this as completed and the WHO certification obtained. This points to the need for better communication between relevant State departments so that goals are streamlined and resources are not wasted. Further, the promise of “electronic web-based information systems will be expanded with networking and data sharing among stakeholders with regard to reproductive rights” is hopeful, we view it with some trepidation with consideration to data privacy. It is vital that any moves to collect data in this manner is done cautiously especially with regard to the data of marginalized populations who are already subject to immense violence and harassment such as people who identify as queer including transgender people, sex workers, people facing IPV. It is mandatory we consider this so as to not have their data exploited to their detriment.

While hopeful – these commitments are far from comprehensive and leave out specific demands that have been made in the last 5 years that are continuing to prevent us from reaching the goals set out in 1994 at ICPD. This includes the which amending the Muslim Marriage and Divorce Act which among other things allows for the marriage of girls aged 12 that Muslim women activists have been highlighting for over three decades; specific criminalization of female genital cutting; the protection and upholding of the rights of sex workers; de-criminization of same sex relations under Section 365 A of the Penal Code; re-drafting of the Domestic Violence Act; and a holistic approach to online gender based violence to name a few.

And the Band Plays On….

To quote the State of the World Population Report 2019 from UNFPA

“Despite progress having been made, hundreds of millions of women today still face economic, social, institutional and other barriers that prevent them from making their own decisions about whether, when, how often and with whom to become pregnant. They still do not have access to contraceptives, girls and women still face sexual violence and suffer from harmful traditional practices including child marriages. They do not have access to affordable, high quality health services or comprehensive sexuality education. They lack the power to make decisions about their own bodies and have to struggle individually and collectively against powerful forces, including religious forces that oppose advances towards gender equality and the respect, protection and fulfilment of girls’ and women’s human rights.

The report recognizes that “of all the obstacles to the achievement and exercise of human rights, few have proven to be as challenging to overcome as those based on gender. Gender, the web of expectations and norms within a society that together define what are appropriate male and female behaviours, roles and characteristics, is learned, internalized and reinforced through social interactions with others, thus having a profound influence on every domain of life”

The fight is far from over, it has barely begun. We need desperately to now move beyond the gender binary, beyond the confines of a public health approach and mainstream and uphold the humanity, dignity and rights of all people going forward. We need to start with education rooted in the fundamental human values of consent, respect, empathy, self-esteem, trust and being sensible. We need to start from the very beginning or once again in 25 years we will be reflecting from the very same place we are doing so now.