Lessons from trailblazers across generations - History matters part 2

In the second of our history matters episodes suggested by you, our listeners, our two guests reflect on their personal experiences and engage in an intergenerational discussion on the evolution of sexual and reproductive health. Host Garry Aslanyan’s guests are Carmen Barroso, a lifetime advocate, researcher and implementer for sexual and reproductive health, and Dakshitha Wickremarathne, senior technical lead overseeing the implementation of FP2030’s Asia Pacific Hub. The discussion highlights how history supports future leaders through intergenerational learning and charts a hopeful path for the evolution of key global health challenges.

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Transcript

Garry Aslanyan [00:00:09] Welcome to the Global Health Matters podcast. I'm your host, Garry Aslanyan. In this episode, we bring you the second instalment of our series focused on global health history. The insightful suggestion for this series came from Erica Nelson. 

Erica Nelson [00:00:27] Hi, this is Erica Nelson. I'm at the Institute of Development Studies at the University of Sussex in Brighton, England, and I am an avid Global Health Matters podcast listener. Some months back I reached out to Garry and Lindi to say, "Hey, what about an episode that focuses on history and why histories, plural, matter to contemporary global health practitioners?" And to my delight, they took me up on this idea and have not one but two history focused episodes, which is absolutely wonderful. The question Garry asked me to reflect on here is, Why did I come in saying that history matters, that you should be incorporating this into an otherwise contemporary focused podcast? And there's many reasons, some already detailed by Sanjoy Bhattacharya and Anne-Emanuelle Birn in the May 9th episode. But to that I would add the importance of engaging with historical perspectives and diverse historical narratives encourages humility. It counters hubris, something of which there is at times too much of in global health practice. It kind of shatters our illusions of control or illusions of linear progress when, in fact, processes of change are often quite a lot messier than that. And by the same token, it can give value to less heard voices of perspectives, ideas and innovation that perhaps were not taken seriously enough or did not get the attention they deserved in their time, but that are still really valuable to the challenges that we face in contemporary global health. So, yes, histories matter and I am very glad that Global Health Matters has taken that point to heart.

Garry Aslanyan [00:01:57] In History matters part two, we will focus on personal accounts of history and experiences. Together with my two guests, we engage in an intergenerational discussion focusing on the evolution of sexual and reproductive health as an example. My guests for this conversation are Carmen Barroso, a lifetime advocate, researcher and implementer for sexual and reproductive health and Dakshitha Wickremarathne. Dakshitha is a development practitioner from Sri Lanka and the senior technical lead overseeing the implementation of family planning 2030s Asia Pacific hub. 

Garry Aslanyan [00:02:42] Carmen, you have had a long and successful career where you have seen many changes and evolutions in global health. For you, how can history support the actions and decisions of future leaders?

Carmen Barroso [00:03:00] Hi Garry. Thanks for this question. I think it's crucial that current and future leaders look at history and learn the lessons, both from the mistakes and from what was achieved. I know that future leaders are facing circumstances that are much different from what we faced in the past, but what we've learned in sexual and reproductive health in the past is fundamental because it's an area that always faced a lot of opposition. Now we are facing a new authoritarian backlash, threatening progress in many areas of global health. This is very similar to what happened in the past with regard to SRHR (sexual and reproductive health and rights).

Garry Aslanyan [00:03:53] Hi Dakshitha. As a global health professional of the millennial generation, is there value for you in understanding the historical context and events of global health?

Dakshitha Wickremarathne [00:04:04] Thank you Garry, and hello Carmen. I think this is a very interesting conversation because when Carmen was speaking, I was reflecting on the current challenges we face as health advocates across the globe, and there's a lot of similarities. Some of these challenges are a continuation from the past 30, 40, 50 years, but some of them are new. And as Carmen said, when you look at particularly on sexual and reproductive health and rights, there are a lot of old challenges historically coming up in our conversations which are also currently relevant. Just like the increase of opposition in terms of making sexual and reproductive health and rights a reality for everyone is similar to the past era. There are funding challenges in terms of funding for sexual and reproductive health and rights to making sure that health is accessible for everyone has become a challenge, particularly for countries or the communities in the lower- and mid-income spaces. But, there are also a lot of new challenges such as climate change, which is having a great impact in terms of communities living across the world. Migration and refugee crises due to various humanitarian scenarios have increased over the years. And above all, I also see that with the technological and digital advances we face, which are very helpful advantages for humans, similarly there are challenges coming up in terms of the human rights violations taking place on digital platforms, which is a very new and an emerging area. So within this context, with all the old challenges and new challenges, there is a lot for us to learn from the historical context and events and influences of global health.

Garry Aslanyan [00:05:47] Let's take a closer look at three historic shifts over the last 40 years and see from your perspective in sexual and reproductive health how they played out. So in part one of the History matters episode that aired earlier with Anne-Emanuelle Birn and Sanjoy Bhattacharya, the notion of health for all had different historical influences. How do each of you see the evolution of this concept since 1978? Since Alma-Ata? Carmen?

Carmen Barroso [00:06:21] Dakshitha talked about the important notion of health for all, and the Declaration of Alma-Ata is very important on many grounds, but what sings to my ears is something I'd like to quote. "Health is a fundamental human right and the attainment of the highest possible level of health is the most important worldwide social goal." This is now recognized, health is a major part of the. Sustainable Development Goals, but this application of this concept of health that's a right was a revolution in public health whose impact continues to expand. Many years later, it brought to light the very area of sexual and reproductive health and rights. In 1994, I had the privilege of participating in the alliance that contributed to the birth of the new notion of sexual and reproductive health. The conference held that year had huge consequences for global health around the world, particularly for women. Previously, women were seen as passive beneficiaries of services. The old paradigm of family planning for curbing population growth was replaced by the new paradigm of reproductive and sexual health. Women then became right-holders, entitled to more than sterilization to avoid having children. They were no longer seen as just the uterus. They were human beings with multiple needs, responsibilities and rights. They had the right to decide. Even the right of participating in the policies that affect their health, their families and their lives. This new paradigm for sexual and reproductive health had its roots in Alma-Ata, but a two way relationship emerged between the evolution of SRH and global health as a whole. The emergence of reproductive health brought new changes in health systems as a whole. Today, reproductive health services are considered essential health services to be provided by primary health care facilities. This transformation was not easy. It required a lot of advocacy and education of policy-makers, providers and women themselves. The Cairo conference was a major landmark in the history of global health, but did not transform health systems overnight. It was just the beginning of a long process that continues today.

Garry Aslanyan [00:09:28] What about you Dakshitha?

Dakshitha Wickremarathne [00:09:29] Well I think reflecting on what Carmen was sharing, since the 1978 Alma-Ata and the Cairo conference, which is a landmark conference for sexual and reproductive health and rights, I think someone who started advocating for sexual and reproductive rights in this millennium, we always look back at the ICP Cairo 1994 programme for action in terms of making sure that the language given in that document, how it has set the tone for the Millennium Development Goals, and then much later on to the Sustainable Development Goals in 2015. I think over these years we have come a long way in terms of not just looking at women and young girls as just beneficiaries, as Carmen said, but also active participants in terms of shaping these policies and programmes, looking at health from a human rights based point of view rather than just looking at it simply from a medical point of view. And in the recent years, I think many other social movements and external factors, such as the racial justice movement, LGBTIQ rights movement, disability rights movement, have also influenced the way we look at health, not just from a very siloed approach, but from a very inclusive and intersectional approach. So we can't have one approach in terms of ensuring that different communities are receiving the same level of support.

Garry Aslanyan [00:11:02] So clearly the road has been long, but we have seen significant progress in the recognition of sexual and reproductive health as a human right and that it needs to be inclusive of the different identities and realities of women. Next, I'd like to ask you both about the shift that has come about in recent years from vertically focused public health implementation to a more integrated approach. How has this influenced sexual and reproductive health?

Carmen Barroso [00:11:33] May I jump in a little bit here?

Garry Aslanyan [00:11:35] Please.

Carmen Barroso [00:11:36] Dakshitha brought a very important point of view that is crucial to consider nowadays of inclusivity and intersectionality and an integrated point of view. I would like to stress that the integrated point of view is very important for the health systems, but it goes beyond the health systems because they bring to mind the social determinants of health and therefore the health systems need to also collaborate and be integrated in a whole government. Like social policies. When they are drafted, they should take into consideration the health effects of poverty, the health effects of factors that go beyond the realm of a ministry of health. And that is integrated within and beyond and across with other sectors in building strategies in collaboration with the whole government.

Dakshitha Wickremarathne [00:12:46] Garry, if I may just add one more thing. When Carmen was talking about her last point, particularly working with the other sectors, a really good example is the importance of education with regard to health. And when we look at it simply from an SRHR point of view, the importance of comprehensive sexual education in schools and how that helps young people and adolescents in terms of making more informed decisions about their bodies, about their lives, and being able to develop core values and principles on mutual respect, appreciating diversity and developing respectful relationships with each other, which definitely helps in terms of improving the health outcomes as well. So as Carmen said, I think it's really important to look at these multiple other social determinants and to work with different sectors when we are trying to achieve health outcomes.

Garry Aslanyan [00:13:42] So multisectoral integration of care is an important evolution. The third factor I want to touch on is the role of advocacy. As I know you're both committed sexual and reproductive health advocates. Carmen, what were the key factors that enabled advocating for sexual and reproductive health as a core component of the health agenda things?

Carmen Barroso [00:14:08] Thanks Garry, this is an important question. I would highlight at least four key factors. One is the role of civil society and especially of national and global women's movements, especially in the southern countries, that was crucial. The second, which is closely related to that, and it's an anticipation of the integrated approach that needs to be taken, is that alliances were formed between those movements, those women's movements for health, with experts, policy-makers from the South and the North, and that was an alliance of strange bedfellows, as has been said, and that's very important for future leaders to consider, is if you want an integrated approach, you have to have integration of a variety of supporters in different social movements. The third factor is the role of science. And it's particularly important because WHO and the programme it has created, the human reproduction programme, that is now co-sponsored by other organizations, has been for over 50 years crucial for advocates because the production of science, the research sponsored by this programme of WHO, could support an advocacy that is firmly grounded in evidence and that gives it important weight in the negotiation for advancing policies. And finally, the role of private foundations and other funders, but especially private foundations where I had more direct knowledge. I would like to highlight a few points about each one of these four areas. In the case of the grassroots feminists, especially from the South, they join forces with feminists from the northern countries too. When I took the initiative to establish a gender studies unit within a foundation in Brazil where I was a researcher, I was accused of complicity with cultural imperialism and of introducing an area of research that was not relevant for a country like Brazil. I was lucky to receive support from abroad, both in funding from foundations, but especially from the community of knowledge that was forming among feminist scholars working in a wide variety of countries such as the US and France, but also in India, in Mexico, in Argentina, and others. The women's movement in particular quickly learned how to lobby national governments and how to influence  intergovernment fora, and with relentless advocacy based on solid evidence. So the paradigm shift did not occur without strong opposition.

Garry Aslanyan [00:17:34] Carmen, could you tell me a bit more about your own advocacy experience? I'm sure you have some accounts to share that younger advocates may not even be aware of.

Carmen Barroso [00:17:43] In the nineties, the Pope drew all his weapons to try to prevent the Cairo conference. He gave interviews to major newspapers around the world, sent letters to Heads of State recommending that they do not send representatives to the conference, and representatives of the Holy See played a relentless role in the preparatory meetings of the conference, obstructing all attempts at consensus. They raised hell and found allies in some Muslim countries. So powerful were those who opposed the change, it looked like they would easily win the battle. The strong opposition from the Holy See backfired. It brought together unlikely bedfellows. Demographers, family planning advocates, mainstream policy-makers, development scholars, feminist researchers and grassroots activists saw the need to discuss their differences and joined forces to resist the massive forces opposing women's rights to access contraceptives. The alliances between academic policy-makers and feminists were quite uneasy at the beginning. Policy-makers and academics spoke different languages. New concepts were being created, making it almost impossible at common understanding. But language was evolving rapidly and becoming a shared currency. I remember a meeting in 1992. An Ambassador from a European country objected to the term reproductive health because it was not part of the lexicon in his native language, he argued. This same diplomat played a major role in Cairo two years later, steering the approval of the Plan of Action centred on reproductive and sexual health. So the evolution was really fast. Now, just a little thing about the role of funders in private foundations, because this is an area that I have direct knowledge in and it's usually little known. I was first the recipient of the support of the foundations and then much later I became the Director of a programme at MacArthur (MacArthur Foundation, United States) in the '90s. In the preparation for the Cairo conference, which took two years of intense mobilization of civil society in all continents, I saw the role of foundations from another angle. The foundation where I work then in the nineties at MacArthur, together with Ford and smaller foundations, supported the networking of Third World women and their participation in international fora. But the foundations went beyond that. We advocated for women's movements to be at the table. At the beginning, at the preparation, the UNFPA, which was responsible for the conference, was trying to avoid much participation from civil society. They were concerned about possible disruption as it happened in 1992 at the Earth Summit in Rio, where women activists fiercely denounced coercive population control policies. MacArthur in 1993, early 93, invited the leadership of UNFPA for a meeting in Chicago with foundations supporting reproductive health. Foundations made the case that the women's movement could be allied if the focus shifted from demographic targets to women's right to decide. So at Cairo, there were two conference, the intergovernmental conference and the NGO conference. And in both, the presence of civil society was very important and UNFPA supported that participation instead of opposing it. And I think this is what made Cairo possible because that seemed impossible that a change would occur, but it ended up being possible. And that's what future leaders, I think, need to try to achieve with the new challenges.

Garry Aslanyan [00:22:22] Carmen, thank you so much for sharing this rich personal historic account. The persistence and tenacity displayed by your generation is remarkable and what you have been able to achieve as a result. Dakshitha, could you reflect on what Carmen said and how this could influence your advocacy efforts?

Dakshitha Wickremarathne [00:22:42] I think what Carmen spoke about certainly influences the advocacy work we are doing right now with some of the same challenges. While I was preparing for this talk, I did a little bit of research and I found this really interesting analysis of the United Nations document and country statements from 2014 to 2019 based on the language on UN conferences, on sexual and reproductive health and rights and how it has changed over time. But since 1994, most of the progressive language which was in the Cairo Declaration, has been actually watered down, which is a very unfortunate scenario, particularly we need to really look at different ways of conducting advocacy and learn from global champions from Carmen's generation and generations later. These opposition to SRHR in global forums has increased, and including in conjunction with an increase in religious far right populist politics, and they use different strategies in terms of bringing more language around the importance of family and using the family-based language, which has been replicated around many UN documents. The challenge we as advocates see with this language is that it takes out the rights individual women and girls have in terms of making decisions on their health by their own but rather looking at very traditional convention family values, which restricts women and girls from accessing contraceptives, in terms of their sexuality and gender identity and in terms of the everyday decisions they would make. So we really need to look at more ways in terms of what Carmen talked about about national and women's movements, in terms of building alliances, working with multiple advocacy coalitions, in terms of achieving rights for all, and truly look at, I think from a decolonization point of view, where we do have to work with foundations and donors, but also to see how we can have a more decentralized way of working in terms of advocacy, to find champions from low- and middle-income countries and bring those committees from those countries to the global platforms in terms of shaping those countries' policies with those civil society champions, but not just necessarily based on the priorities given to us by the people who are giving us the financial support.

Carmen Barroso [00:25:13] May I, quickly? I think that Dakshitha brings a lot of important points here and I recognize the validity of all that he's saying. But I think we have to balance this clear eyed look at the setbacks, with looking beyond the UN documents, or maybe even in the UN documents we can also see a much wider reach of the ideas, on the positive side, too. And I like to bring this need for looking at the progress that is still today remains in spite of all these challenges that are so real that Dakshitha has so clearly outlined, is that..., look at the gender rights. I was so sad to read the news about Poland where this young man of 15 years committed suicide because of the terrible harassment that he suffered for being the victim of sexual abuse. And I thought that there is nothing more horrible than that, but the fact that this is now an object of interest in the international press is something that is affecting the way societies are revisiting their values and their approach. No matter how much the documents are watering down the language, there has been a dissemination of ideas that even the conservatives are assuming and adopting, even if not widely acknowledging that. But I feel when I look around and every day everywhere, I feel things that are amazing to me still. You know, I'm 78 years old, and even the word transgender didn't exist in our vocabulary. So I think there is much more positive that we have to look so that we don't lose the hope. And if we only see the tremendous obstacles that are real and continue to exist, we lose perspective and we lose hope, and without hope, we don't do anything.

Garry Aslanyan [00:28:35] Based on what you both shared, I hear that intergenerational knowledge sharing can be very valuable in advancing global health, and it is also important to focus on the positive achievements, even if small, as a way to not get discouraged. Carmen, as we come to close, what advice would you have for current and upcoming leaders and advocates on documenting their experiences such that it can give us that enriched historic perspective capable of informing and inspiring action?

Carmen Barroso [00:29:11] They should give me advice. But they may change these three things. First, they should take this time for reflection and share with future generations because human memory is short-lived and the significance of what was achieved in the recent past might escape those who have not lived at the time they were achieved. New generations may take for granted what was conquered with hard work by previous generations. The second thing I would say, look also at the mistakes to extract lessons learned because they might be proving useful for future generations too. And the third is what I was talking about, the preservation of hope. I think leaders should not be shy about sharing the accomplishments and the achievements that they are having right now because new generations need hope to have the energy and the persistence needed for building a better world. Without hope we don't have the energy and persistence which is much, much needed, it's not easy work. Let's help them to make the impossible possible.

Garry Aslanyan [00:30:28] And Dakshitha, what request may you have of mature global health leaders on the role they can play even after their period of active duty is over?

Dakshitha Wickremarathne [00:30:39] I think that when I look at global health leaders, true champions like Carmen, I think there's no way that they are out of active duty, I think always championing the work of SRHR and gender equality and I think within that there's still things like actively engaging in mentoring with young professionals from generations, I think truly that would be very helpful. And the final request is to, as I said earlier, keep doing what you do every day. You have made brilliant progress over the years in terms of pushing for human rights and women's rights and Cairo and Beijing Declaration to action, with the MDG conversations and SDG conversations and that has really helped advance sexual and reproductive health and rights and global health in the recent years. If you look at a few examples in Portugal, Iceland, Argentina, there were many laws around same sex marriages were implemented, in Uruguay in 2012 they decriminalized the abortion laws, China relaxes their one child policy, and similar to that, even through the SDGs, unlike the MDGs, the SDGs were able to bring very specific sexual and reproductive health related targets and indicators, which then all those achievements we had because the health advocates deal with the opposition we have right now and making sure that women and young girls across the world will have access to sexual and reproductive health and rights.

Garry Aslanyan [00:32:13] Thank you both for sharing your experiences and perspectives. I wish you the best of luck with your future endeavours.

Carmen, Dakshitha [00:32:21] Thank you. Thank you Garry. 

Garry Aslanyan [00:32:24] I hope you, our listeners, enjoyed this conversation as much as I did. For me, it really highlighted the value of intergenerational sharing and learning. Carmen clearly articulated the value of reflection. In global health we can often become consumed with doing so much, especially as the challenges are so significant. However, pausing and reflecting on the progress made by all of us can yield valuable learning and help global health practitioners not to lose hope, even when the road is long. Dakshitha made a call to all mature global health professionals to engage in mentorship, such that the next generation can build on the shoulders of the giants who came before them. In developing this episode, we worked closely with HRP, the WHO Programme on Human Reproduction health. HRP was established in 1972 and has a distinguished record of supporting and coordinating research on a global scale. For example, research into contraception, abortion, maternal health and violence against women. Our thanks to HRP for their advice and input on this episode. To learn more about the topics discussed in this episode, visit the episode web page where you will find additional readings, show notes and translations. Don't forget to get in touch with us via social media, email or by sharing a voice message with your reflections on this episode.

Elisabetta Dessi [00:34:08] Global Health Matters is produced by TDR, a research programme based at the World Health Organization. Garry Aslanyan is the host and the Executive Producer. Lindi Van Niekerk and Obadiah George are content and technical producers. The podcast editing, communication, dissemination, web and social media designs are made possible through the work of Maki Kitamura, Chris Coze, Elisabetta Dessi, Izabella Suder-Dayao and Chembe Collaborative. The goal of Global Health Matters is to produce a forum for sharing perspectives on issues affecting global health. Send us your comments and suggestions by e-mail or voice message to TDRpod@who.int, and be sure to download and subscribe wherever you get your podcasts. Thank you for listening.