Law, Human Rights, and Women’s Health

1. Law, Human Rights, and Women’s Health David Barnard, PhD, JD University of Pittsburgh School of Medicine School of Law Center for Bioethics and Health Law

2. Overview • Introduction • Brief overview of women’s health status in Ethiopia. • Ethiopia’s Federal Constitution and human rights commitments • Exploring the mismatch: • Gender inequality • Social determinants of health • Customary law and the relative imperviousness of custom to international norms • Two human rights narratives • An example from Botswana of interactions between narratives

3. Introduction: Two Narratives

4. A. “The Human Rights Revolution”

5. Some Major Human Rights Treaties • Universal Declaration of Human Rights (1948) • Convention on the Prevention and Punishment of the Crime of Genocide (1951) • International Covenant on the Elimination of All Forms of Racial Discrimination (1969) • International Covenant on Civil and Political Rights (1976) • International Covenant on Economic, Social and Cultural Rights (1976) • Convention on the Elimination of All Forms of Discrimination Against Women (1981) • Convention on the Rights of the Child (1990)

6. B. Women’s Inequality and its Health Consequences The face of poverty in Africa is still a woman, the face of HIV/AIDS is still a woman. It is easier to change structure, but it is not easy to change patriarchy. --Micheline Ravololonarisoa, Chief, Africa Section, UNIFEM, July, 2006

9. Poverty and Patriarchy → • Maternal Mortality • HIV/AIDS • Female Genital Cutting • Occupational Illness • (among others)

10. Do these narratives have anything to do with each other? What, if anything, should advocates for women’s health expect from the human rights regime as tools or resources for improvement in women’s health?

11. 2. Brief overview of women’s health status in Ethiopia

12. Ethiopia

14. HDR 2007/08 Life expectancy at birth, annual estimates (years), 2000-05 • Ethiopia 51.8 • Sierra Leone41.8 • Iceland81.5 • USA 77.4 Adult literacy rate (% aged 15 and older), 1995-2005 • Ethiopia 35.9 • Italy 98.4 • Sierra Leone34.8 • USA 99 GDP per capita (PPP US$), 2005 • Ethiopia 1,055 • Iceland 36,510 • Sierra Leone806 • USA 41,890

15. Population living below $1 a day (%), 1990-2005 • Ethiopia 23.0 • Sierra Leone57.0 • Republic of Korea<2 • USA (no data) Population living below $2 a day (%), 1990-2005 • Ethiopia 77.8 • Chile 5.6 • Nigeria 92.4 • USA (no data) Population using an improved water source (%), 2004 • Ethiopia 22 • Iceland100 • Sierra Leone57.0 • USA 100

16. Population using improved sanitation (%), 2004, • Ethiopia 13 • Iceland100 • Sierra Leone39 • USA 100 Population undernourished (% of total population), 2002/04 • Ethiopia 46 • Iceland<2.5 • Sierra Leone51 • USA <2.5 Physicians (per 100,000 people), 2000-04, • Ethiopia 3 • Iceland362 • Sierra Leone3 • USA 256

17. Maternal mortality ratio, reported (per 100,000 live births), 1990-2004, • Ethiopia 870 • Iceland4 • Sierra Leone2,100 • USA 11 Births attended by skilled health personnel (%), 1997-2005 • Ethiopia 6 • Norway100 • Niger 16 • USA 99

18. Infant mortality rate (per 1,000 live births), • Ethiopia 80 • Iceland2 • Sierra Leone165 • USA 6

19. Female Genital Cutting • In 1997/1998 the National Committee on Traditional Practices in Ethiopia (NCTPE) carried out a national baseline survey—72.7 % of the female population have undergone one of these procedures. • Regional statistics of the prevalence from the survey are: Afar Region—94.5%; Harare Region—81.2%; Amhara Region—81.1%; Oromia Region—79.6%; Addis Ababa City—70.2%; Somali Region—69.7%; Benseshangul Gumuz Region—52.9%; Tigray Region—48.1%; Southern Region—46.3%. U.S. Department of State

20. 3. Ethiopia’s Federal Constitution and Human Rights Commitments

21. Article 9 • 9(1) The Constitution is the supreme law of the land. Any law, customary practice or a decision of an organ of state or public official which contravenes this Constitution shall be of no effect. • 9(4) All international agreements ratified by Ethiopia are an integral part of the law of the land.

22. Article 13 • 13(2) The fundamental rights and freedoms specified in this Chapter shall be interpreted in a manner conforming to the principles of the Universal Declaration of Human Rights, International Covenants on Human Rights and international instruments adopted by Ethiopia.

23. Human Rights Instruments Adopted by Ethiopia • International Convention on the Elimination of All Forms of Racial Discrimination, 1976 • International Convention on the Elimination of All Forms of Discrimination Against Women, 1981 • Convention on the Rights of the Child, 1991 • International Covenant on Civil and Political Rights, 1993 • International Covenant on Economic, Social and Cultural Rights, 1993 • Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, 1994 • Africa Charter on Human and Peoples’ Rights, 1998

24. Article 35 • 35(1) Women shall, in the enjoyment of rights and protections provided for by this Constitution, have equal rights with men. • 35(2) Women have equal rights with men in marriage as prescribed by this Constitution.

25. Article 35 • 35(4) The State shall enforce the right of women to eliminate the influences of harmful customs. Laws, customs and practices that oppress or cause bodily or mental harm to women are prohibited. • 35(9) To prevent harm arising from pregnancy and childbirth and in order to safeguard their health, women have the right of access to family planning education, information and capacity.

26. 4.Exploring the Mismatcha. Gender Inequality

27. Adult literacy rate (% aged 15 and older), 1995-2005, 35.9 • Adult literacy rate, female (% aged 15 and older) , 2005, 22.8 • Adult literacy rate (ratio of female rate to male rate), 2005, 0.46

28. Youth literacy rate (% aged 15-24), 1995-2005, 49.9 • Youth literacy rate, female (% aged 15-24), 2005, 38.5 • Youth literacy rate (ratio of female rate to male rate), 2005, 0.62

29. Net primary enrolment rate, female (%), 2005, 59 • Net primary enrolment rate (ratio of female rate to male rate), 2005, 0.92 • Gross secondary enrolment ratio, female (%), 2005, 24 • Gross secondary enrolment ratio (ratio of female ratio to male ratio), 2005, 0.65 • Gross tertiary enrolment ratio, female (%), 2005, 1 • Gross tertiary enrolment ratio (ratio of female ratio to male ratio), 2005, 0.32

31. Women in government (as % of total), Parliament, 2008, 21.9 Ministerial level, 2008, 7.7

34. 4. Exploring the Mismatchb. Social determinants of health

35. The [first] example is that of a dead woman who had been given in marriage at 13 years of age. She lost her first pregnancy but was damaged due to obstructed labor resulting probably from disproportion between the baby’s head size and her birth structure. Three years following the repair of her damaged birth canal she again became pregnant. At seven months pregnancy she started bleeding after carrying a heavy jar of water from a distant source. She started labor the same day but did not make it to the hospital until three days later. By then the baby had no sign of life and she was in severe distress. She was delivered and the uterus was removed. On the 27th day of admission and medical care she passed away.

36. There is not a single cause for her death. Being young, married, doing heavy work during pregnancy, physical disproportion, no health services close by and no time to seek out the far away health service—all contributed. The gender-assigned job of fetching water does not relate to the sex-designated role of pregnancy. All jobs other than pregnancy, labour, delivery, and lactation could be shared, if it were not for society’s prescription of gender-segregated roles, of which the most burdensome and routine are assigned to women. Kidanemariam Adenech and Tamirat Azeb. “Gender Influence on Women’s Health: A Review of the Ethiopian Situation.” In: Tsehai Berhan-Selassie, ed. Gender Issues in Ethiopia. Institute of Ethopian Studies, Addis Ababa University, 1991. Proceedings of the First University Seminar on Gender Issues in Ethiopia, Addis Ababa, December, 1989

37. In 1990, over one-third of married women between 15 and 49 were married before the age of 15, while 41% married between the ages of 15 and 17. Mean age of marriage in rural areas is estimated at 15.2 years for girls and 21.5 years for boys. In the northwestern region of the country it was estimated in 1990 that at least half of the women married at the age of 14 or younger. -Center for Reproductive Rights

38. Fertility rate, total (births per woman), 2000-05 • Ethiopia 5.8 • Iceland2.0 • Niger7.4 • USA 2.0 Contraceptive prevalence rate (% of married women aged 15-49), 1997-2005, • Ethiopia 15 • China 87 • SierraLeone4 • USA 76 Condom use at last high-risk sex, women (% aged 15-24), 1999-2005, • Ethiopia 17 • Niger7 • Botswana75 • USA (no data)

39. 4. Exploring the Mismatchc. Customary law and the relative imperviousness of custom to international norms

40. Article 34 • 34(5) This Constitution shall not preclude the adjudication of disputes relating to personal and family laws in accordance with the religious or cultural laws, with the consent of the parties to the dispute. Particulars shall be determined by law.

41. Proportion of respondents agreeing with statements on equality between sexes, and mean score of “positive” gender equality responses

43. Chege, Jane et. Al. “Testing theEffectiveness of Integrating Community-Based Approaches for Encouraging Abandonment of Female Genital Cutting into CARE’s Reproductive Health Programs in Ethiopia and Kenya”

44. 5. Two Human Rights Narratives

45. Do these narratives have anything to do with each other? What, if anything, should advocates for women’s health expect from the human rights regime as tools or resources for improvement in women’s health?

46. Forms of Action for Promotion of Human Rights • Recognition • Agitation • Legislation Amartya Sen, “Elements of a Theory of Human Rights,” Philosophy & Public Affairs, 2004, 32(4): 315-356.