The 2012 Global Family Planning Summit: Will Issues Be Adequately Addressed?

@RHRealityCheck

In mid-July, world leaders will gather in London to discuss a real and urgent need: increased funding for family planning. Over the past 15 years, the United States—one of the largest foreign aid donors in the world—has cut its funding level for family planning by at least 25 percent. Meanwhile, the demand for modern contraception and family planning information has only increased. By most accounts, an investment of approximately $6.7 billion is needed annually to meet current needs for family planning.

The summit documents, which is co-hosted by the Bill and Melinda Gates Foundation and the UK Department for International Development and supported by the US Agency for International Development and the UN Fund for Population Action, link the dearth of contraceptives and health services to poverty: women in “rich countries” have what they need, whereas women in “poor countries” don’t. This notion is supported by the fact that over 99 percent of maternal mortality happens in so-called developing countries.

This vision is not so much wrong as it is incomplete.

In early 2010, the medical journal The Lancet published new research on maternal mortality and morbidity. The research showed that improvements in maternal health — a good indicator for women’s access to health services overall — depend on 4 key factors, only one of which has to do with family planning: 1) lower fertility; 2) higher education levels for women and girls; 3) rising per capita income overall; and 4) access to skilled birth attendants.

Importantly, both the Global Family Planning Summit and research published in The Lancet potentially obscure the fact that adequate access to contraceptives and health services is a question of income rather than geography. To be blunt, a wealthy woman in a poor country is likely to have better access to care than a poor woman in a wealthy country.

Just as importantly, all four drivers of healthy motherhood depend on women’s ability to exercise their human rights, including the rights to quality health care, non-discrimination in education and health, and economic empowerment through job creation and protections for equality in the workplace.

But perhaps most to the point, the much-needed infusion of extra cash to development aid budgets for family planning is a means to an end. For the organizers of the London summit, that end is the provision of family planning services to poor women in the developing world. But even this very laudable objective is also a means to an end — or at least it should be.

Almost two decades ago the world’s governments for the first time promoted an understanding of individual empowerment as a vehicle for better policy outcomes on population growth, through the 1994 Cairo Declaration on Population and Development. The measures set out in this declaration supported the, at the time, radical notion that if individuals are empowered to make their own decisions about their family’s size and growth, these decisions, in the aggregate, will make for healthy and balanced societies. This notion departed from previous decades for population control through central planning and imposed government targets for fertility.

Of course a piece of paper is one thing. A real commitment to change is something else.  In the 18 years that have passed since the adoption of the Cairo declaration, few governments have shown a sustained commitment to actually empower all individuals, equally, to make decisions about their families.  

Some impose limits on family growth, punishing all women for wanting to have larger families than the government mandate. Others seek to limit the fertility of specific individuals within their population who for some reason or other are deemed unworthy parents, usually because of their color, class, family status, or gender identity. Still others force women to have larger families than that might have wanted through demonizing contraception, encouraging (or ignoring) early and forced marriage, and by perpetuating a culture where women without children are seen as somehow incomplete.

None of these situations promotes the kind of autonomy in family planning envisaged by the world community in 1994. And neither will merely stockpoling contraceptive methods.

The latter, however, will help. Here’s to hoping that the education, economic empowerment, and equality needed to ensure real family planning won’t be far behind.

Crime and Obesity: Let's Get to the Heart of the Problems

@RHRealityCheck

There is something deceptively simple about New York City mayor Michael Bloomberg’s blanket initiatives. Whether it is giving the police unfettered discretion to stop and frisk anyone they think might look like a potential criminal because “it saves lives,” or banning the sale of large-container sodas because, well, that saves lives too, the initiatives promise easy fixes to complex problems.

They are, however, based on a blindness to prejudice that is compelling precisely because it is wrong.

In short, Mayor Bloomberg’s initiatives purport to be color- and class-blind. If the stop-and-frisk program affects mostly men of color, Bloomberg argues, this is purely coincidental. And if most of New York City’s overweight population lives in the poorest boroughs, that is also just by chance. Maybe, this line of argument implies, it is just that men of color and the resource-poor make appallingly bad decisions about their lives and health.

Incidentally, I am not arguing that our definitions of what should be subject to punitive measures and what constitutes a “normal” weight are perfect or even always good. The point I am making is about policy effectiveness. And in that sense, even a cursory look at correctional and obesity statistics in the United States reveals deep-seated disparities which knee-jerk reactions — in particular those that blatantly ignore color and class —cannot fix.

For example, 87 percent of those stopped and frisked in New York City in 2011 were either black or Latino and mostly male, even though drug possession and use — the ostensible reason for most stops — is equally prevalent among whites. And on health, compare the pricing of a Happy Meal and a pound of organic locally grown apples and you might have an idea of why the poor constitute the majority of the nation’s obese, and why many of them, at the same time, are malnourished.

Here’s a hint: It’s not because we don’t know better. 

Obesity, like being caught in the criminal justice system, is a condition disproportionately suffered by the poor and the relatively powerless. And it is self-perpetuating. Extra padding, much like a criminal record, is easier to acquire than to shed.

To articulate these truths is not to say that overweight individuals and those in conflict with the law are immoral, stupid, or devoid of agency and responsibility. It is not even to say that the decisions that led to the obesity and punishable behavior necessarily all are bad.

It is simply to acknowledge that all of us make decisions within our specific constraints, and that policy initiatives that seek to influence these decisions must look for ways to eliminate the constraints.

In the current case, our approach to crime and weight is better understood as wilfully ignored discrimination. The Supreme Court has pretty much systematically sidestepped and ignored racial profiling in the criminal justice system, resulting in continued discriminatory outcomes. And though discrimination against overweight individuals is prevalent in the workforce — in particular when it comes to obese women — only the state of Michigan and six cities ban this type of discrimination directly. This creates a vicious cycle of discrimination which perpetuates existing class and color disparities — a reality that policy initiatives to end both crime and obesity will have to contend with to be effective.

So why do politicians push for color- and class-blind initiatives? A key reason is that solutions to discrimination are more complex (and thus harder to sell to the public) than those which punish individual choice.

Take public school lunch. Many children depend on public schools almost entirely for their culinary development.  In New York City, for example, 62 percent of all children qualify for free school lunch, and many who don’t qualify still eat both breakfast and lunch at school. As a result, if food at school is overly fatty, salty, or sweet, this is what our children’s palates become accustomed to. The federal government has issued new guidelines to address this issue, but cooking healthier food in school cafeterias requires time, and time requires better benefits and higher salaries for cafeteria workers. Meanwhile, schools blame parents for not contributing, and increased money for school lunches is not high on the political agenda.

My point is: It should be.

Instead of spending money on policing serving sizes for sodas at the gas station, New York City Hall would do well to help instil healthy eating habits in children in the first place. And focusing on effective anti-obesity measures will probably save more lives than any amount of stopping and frisking. After all, heart disease has been the leading cause of death in New York City for at least the past decade.

Either way, there is no excuse for the discrimination that is inherent in current approaches to both crime and weight.

Spanking Your Child: The World Disagrees

@RHRealitycheck

Opinion pieces for and against corporal punishment of children cycle around with tremendous regularity. Most are based on absolutely no data, and merely offer some variation on the theme of “I was (or I wasn’t) spanked as a child, and look how well I turned out.”

Many articles inexplicably extrapolate from these hyper-personal narratives to conclude not only that “what’s good enough for me is good enough for my children,” but moreover that whatever the other camp is proposing (to spank or not to spank) is inherently bad for the child with no reference to statistics or science. Most recently, a proponent of spanking argued that not to spank your child teaches her or him that “if life isn’t fair, then throw a fit and you’ll eventually get your way.”

Full disclosure: my parents did not hit or spank me and I have never thought it necessary, desirable, or expedient to hit or spank my child. I know for a fact that she is absolutely clear that throwing a fit won’t get her anywhere. And I also know for a fact that these personal experiences cannot be translated into a theory of child psychology for larger gain.

Instead, let me try to overcome some of the dearth of information on this topic, from the perspective of desired objectives and actual outcomes.

First of all, it might come as a surprise for readers in the United States that many countries have outlawed all forms of corporal punishment of children, including spanking, slapping, other forms of hitting, as well as kicking and shaking. Countries with full bans on corporal punishment include Austria, Denmark, Finland, Germany, New Zealand, Norway, Spain, and Sweden, as well as Bulgaria, Latvia, Lithuania, Macedonia, Moldova, Poland, South Sudan, and Ukraine. (For a full list, see here).

Sweden was the first country to pass a ban on corporal punishment in 1979, and quite aside from impressive child health and education indicators, it is clear that the country has not descended into anarchy as a result of this “lack of discipline.” It is noteworthy that Sweden’s standard of living has been described by economists as “enviable,” fuelled by a “skilled labor force” (including a substantial number of workers born after the absolute spanking ban). Moreover, the economic downturn that is engulfing all of Europe is projected to be relatively short-lived in Sweden. In other words: either it pays off to be throwing fits, or else the ban on spanking does not really produce lazy, fit-throwing adults after all.

To be clear, I am not suggesting that there is any direct causal link between bans on corporal punishment and a country’s economy. I am, however, suggesting that hitting children (whatever you choose to call it) is not something most people agree with. And not because I wasn’t spanked myself. Rather, every single country in the world except for the United States and Somalia, have agreed that spanking is wrong, at least in principle, through ratifying the universal treaty on children’s human rights, the Convention on the Rights of Child. (South Sudan also has not ratified this treaty, but banned corporal punishment of children in 2011).  

In other words, the vast majority of the world’s seven billion individuals live in countries that have, in principle, signed and ratified commitments to end violence against children in all its form, including corporal punishment in the home.

To be sure, the fact that governments from all over the world have come together to declare that spanking must stop is not going to convince those who believe in spanking as an effective method of discipline that, in fact, it is not. 

To this there is only one thing to say: they are wrong. 

It is a generally accepted notion that positive reinforcement brings about more lasting behavioral change than punishment both when it comes to animals and when it comes to people. A recent article in The Atlantic notes that theories on how to modify behavior through positive reinforcement form the backbone of successful programs such as Weight Watchers and AA, and provide the underlying structure of newer behavior modification applications for smart phones and computers. 

Indeed, observing children around me, it seems likely that what might produce “lazy fit-throwing” adults is not lack of corporal punishment but rather lack of clarity with regard to what constitutes acceptable behaviour in the first place. There are any number of ways to communicate this clarity, and violence—including spanking—is not one of them. Consistent quality education at home and at school would be a better place to start. 

Is Criminalization of HIV Transmission Effective? Swedish Case Reveals Why the Answer is No

@RHRealityCheck

Earlier this month, a 31-year-old woman in Sweden was sentenced to one and a half years in prison for having unprotected sex without disclosing to her partner beforehand that she is living with HIV.

Even a perfunctory news search reveals that this is not the first time the Swedish justice system has applied criminal sanctions to potential HIV-transmission. In January, a 20-year-old man was sentenced to eight months in prison for having unprotected sex without disclosing his status. In December 2006, a 34-year-old woman got two months, and in January 2003, a 32-year-old woman one year. All of these sentences also required the person living with HIV to pay monetary damages to their former sex-partners.

For anyone who cares about human rights from a health and discrimination angle, these cases raise multiple red flags.

For starters, consensual sex between consenting adults should, in principle, never be subject to government control or regulation. Moreover, the criminalization of HIV transmission has multiple negative outcomes. It leads to distrust in the health and justice systems; it can discourage people from seeking to know their HIV status; it adds to the stigmatization of those living with HIV; and it is ineffective in bringing down HIV transmission.

In fact, UNAIDS (the Joint UN Programme on HIV/AIDS) recommends that governments limit criminal sanctions for HIV transmission to cases where all of three conditions are met: the person charged 1) knows he or she is living with HIV; 2) acts with the intention of transmitting the virus; and 3) actually transmits it. UNAIDS also recommends that cases of such intentional HIV-transmission should be tried under generic criminal provisions for bodily harm or assault, and not under HIV-specific provisions.

Public health and human rights activists are clear on this. That is why the Swedish Embassy in France was defiled with paint-filled condoms in protest against the 2003 ruling. And that is also why my own reaction to the ruling was to declare it “bad” over twitter, a statement that was re-tweeted several times.

A closer read of the cases highlighted in the Swedish media, however, leads me to reconsider, at least in part. 

If the media-accounts are accurate, the Swedish government has, in fact, partially followed UNAIDS recommendations. The convicted individuals all knew their HIV status and the cases were brought under general criminal law provisions on grave assault, physical abuse, and attempt to cause physical harm. So far so good.

The two remaining questions — intent and actual transmission — are more difficult to gauge.

Consider this.  

In most of the cases, the convicted person either has multiple convictions over several years for the same thing, or the conviction is based on multiple unprotected sexual interactions with different partners without disclosure. It is perhaps valid for prosecutors to ask if, absent proof of intent which is hard to produce, the fact that an individual living with HIV repeatedly and knowingly exposes someone else to a deadly virus shouldn’t count for something.

Further, actual HIV transmission may not be the only harm caused. The 20-year-old convicted man was charged with having unprotected sex with eight women, none of whom ultimately ended up HIV-positive, though they all claimed to have suffered severe emotional trauma as a result of the experience. In cases of domestic violence we often ask prosecutors to consider emotional distress as real harm, so why require actual transmission in order to prove harm in this case?

Then again, consider this.

The 20-year-old man was born HIV-positive and is being charged as an adult also for those unprotected sexual encounters that occurred when he was a teenager. He was initially placed in solitary confinement, seemingly because of his HIV status.

Also, one of the convicted women alleged she had been raped.  The male partner produced evidence to the contrary and she later withdrew the allegation. Nevertheless, coercion and fear is highly relevant when it comes to decisions about how and when to disclose HIV status. Research indicates that many women in fact are reluctant to disclose their HIV status because they quite legitimately fear abuse.

And with regard to actual harm caused, it is at least possible that the ramped-up attention to the cases have contributed in some part to the severity of the emotional distress of the sex partners.

It is, of course, reckless to knowingly expose anyone to real danger, also through potential HIV-transmission, even if the danger ultimately does not materialize. This is a notion the UNAIDS recommendations to a large extent fail to acknowledge.

But the highly publicized use of the criminal law in Sweden to punish those living with HIV for being timid about their health status does not make it easier for anyone to disclose. So perhaps the real question with regard to any government’s approach to HIV transmission should not be whether it follows UNAIDS recommendations, but rather if it is effective.  An educated guess says, not so much.

Cameron Government Versus European Court of Human Rights: A Time to Not Act

@HuffPostUK

On 18-20 April, European leaders will come together in Brighton, United Kingdom, to decide the future of the European Court of Human Rights. The importance of this meeting - and the potential for damage - cannot be overstated. For over 50 years, the European Court on Human Rights has helped define state obligations and individuals rights in jurisprudence that is readily cited in national and regional courts worldwide.

Over the years, the Court has clarified that states cannot criminalise same-sex relations, must provide pre-emptive protection to prevent domestic violence from happening in the first place, and has to make access to legal abortion effective, including by providing services. That's in addition to the many cases dealing with the absolute prohibition of torture, equal access to justice, and compensation for discrimination and abuse.

Of course, the court has not been perfect. A key reason for this has been its unequal application of the so-called 'margin of appreciation', a legal concept that is meant to allow governments some room to determine how they plan to fulfil a specific human right within their territory, while not relinquishing the most basic concept behind human rights: that they are universal and apply equally to everyone.

The court has used this concept, among other things, to abdicate responsibility on sex education and broadening access to necessary health care. And while it is absolutely true that human rights are not implemented in a cultural and historical vacuum, it is also true that if the main adjudicator of what is right and what is wrong adopts a relativist and overly subjective approach to making that determination, the very idea that human dignity can be protected is at stake.

In Brighton this week, the UK and some other governments will actively seek to broaden the application of the 'margin of appreciation'. In fact, these governments are so hell-bent on hampering the European Court of Human Rights' ability to determine when they have violated the dignity and livelihood of those living in their territory that they hope to prevent cases from reaching the court in the first place, by giving "margin of appreciation" a meaning it never had.

So far, the court has deferred to governments through the 'margin of appreciation' only when a case has reached the level of substantive discussion, and not in its determination of whether an individual is allowed to bring a case or whether the subject matter is within the court's jurisdiction.

In other words, even where the court has given states wider wiggle-room to limit human rights than one might desire, the individual whose rights were at stake had her or his day in court.

In advance of the Brighton meeting, the UK government has circulated a proposal that would require the court to defer overly to national courts, even before it looks at a case at all. The proposal urges the court to refuse to hear most cases in which the national court has already applied the European Convention of Human Rights in its deliberations.

It is easy to imagine a situation where a national court is unaware of the proper application, status, and scope of legislation and precedents its judges have limited experience with. But more damningly, the proposal undermines the very objective of the European Court of Human Rights: as an additional forum of appeal for human rights issues that may not have been adequately considered at home.

If this proposal is adopted, the UK would have succeeded in limiting oversight of its own human rights practices (and there are any number of issues that merit review). The UK would, however, also have succeeded in significantly weakening an institution that helps--even if at times imperfectly--to uphold standards celebrated worldwide as necessary and just.

All eyes should be on Brighton this week to ensure that the European Court of Human Rights is allowed to do its job: hold governments to their promise to protect the human rights of all.