The Cairo Consensus: Challenges For U.S. Policy at Home and Abroad
Population and development assistance are cornerstones of U.S. foreign policy goals to promote and sustain democracy and economic security overseas. U.S. policymakers have long recognized that rapid population growth is detrimental to political, economic and social structures in developing countries. In an increasingly interdependent world, one country's political and economic well-being is intricately linked with that of others.
Population assistance in the larger context of development policy addresses fundamental needs of families. It provides men and women with the means to take control of their lives, which in turn leads to stronger, more self-sufficient communities that enhance the likelihood of prosperity at the national level. Ultimately, developed countries also benefit in the form of new markets for their goods and services; moreover, the incidence of political crises in need of international intervention and peacekeeping activities may subside with greater political and economic stability.
The 1994 United Nations International Conference on Population and Development (ICPD) held in Cairo served as the platform for officially launching a new era of population policy and politics. The degree of worldwide consensus achieved at the conference in Cairo was unprecedented: 180 nations endorsed the final Program of Action as a blueprint for population and development programs over the next 20 years.
On the surface, the population and development agenda may seem relevant to developing countries only. A closer look at the conference recommendations, however, indicates otherwise. The broad range of short- and long-term recommendations concerning health care, education, poverty alleviation and economic growth are applicable here at home and throughout the industrialized world.
Consider, for example, the issue of teenage pregnancy and its impact on society in the United States. Federal and state lawmakers alike are exploring ways to reduce birthrates among U.S. teenagers. However, in order to effectively address too-early childbearing, its root causes chronic poverty, poor quality or limited access to education and lack of economic opportunities, as well as unmet needs for reproductive health services must be addressed. These are the very issues dealt with in the Program of Action and its recommendations.
This Issues in Brief outlines the underlying policy themes of the Cairo Program of Action and its emphasis on integrating population strategies and programs into the broader economic development agenda. It examines the implications of Cairo for U.S. domestic policy, especially as Congress and state legislatures consider health care and welfare reform in the midst of major budget cuts. Further, it explores what the U.S. endorsement of the Program of Action means for U.S. humanitarian and development assistance, and for population programs in particular.
The Program of Action
The 16-chapter document that emerged from Cairo is as comprehensive in its analysis of population and development concerns as it is detailed in its recommended strategies for critical issues such as girls' education, maternal and child health, economic development and poverty alleviation. It affirms repeatedly the central role of families, which should be protected and strengthened. Integral to the health of families is the role of women-their overall status and their involvement at all levels of economic, political and social development.
In Cairo, the nations of the world acknowledged that population, development and the environment are integrally linked and cannot be addressed in isolation from one another. The Program of Action anchors population at the center of the global economic development agenda. It outlines the fundamentals of a sound population policy, and stresses the importance of the "right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children, and to have the information and means to do so." For the first time, the international community abandoned demographic targets and condemned the use of incentives or disincentives as tools for reducing population growth. The Cairo document is striking in its insistence that enabling men, women and their communities to become self-sufficient is fundamental to the strategic and economic interests of all countries.
Quality of life. The theme of women's "empowerment" and its positive impact on the family through expanded access to primary and reproductive health care, education, and economic and political opportunities permeates the entire Program of Action. The document underscores the fact that women are the primary caregivers, household managers and food producers in many parts of the world. Therefore, countries agreed, successful development strategies at both the national and local level hinge on improving the quality of life for women and their families.
Improving the welfare of the girl child is another prominent theme of the Program of Action. It recognizes that the path to enhancing women's status begins with substantial investment in comprehensive health care, including reproductive health, and in basic education for girls and young women. Ensuring their access to good schooling and health care provides girls and young women with the knowledge and the means to delay pregnancy and time their childbearing as they wish, and it prepares them for adult participation in the social, economic and political spheres of society.
Family planning. No international dialogue on population policy is complete without discussing the key role of family planning. The Cairo conference was no exception; yet, it cast family planning services in a new context-as part of the broader objective to provide comprehensive reproductive health care to men and women. An entire chapter in the Program of Action is devoted to reproductive health, which is defined to include prenatal care, delivery services, family planning and treatment of reproductive tract infections and sexually transmitted diseases. Countries agreed that the provision of reproductive health services should be the focus of population initiatives, maintaining that improving the health of women promotes family well-being and self-reliance.
With respect to abortion, the document falls short of calling for global legalization of the procedure. The Program of Action stresses that abortion is not and should not be viewed as a method of family planning. At the same time, it acknowledges the widespread incidence of unsafe abortion as a major public health concern and urges governments to ensure that where abortion is "not against the law," it be safe.
U.S. Domestic Policy
Throughout the three-year preparatory process leading up to Cairo, the United States strongly supported the goals of the ICPD and, together with countries as diverse as Pakistan, Norway and Nigeria, took the lead in forging the extraordinary level of consensus achieved in Cairo. With the conference over and the Program of Action finalized, the challenge facing all countries is translating the rhetoric into meaningful programmatic changes.
At first glance, the Cairo agenda may seem irrelevant to a wealthy industrialized country like the United States. Rapid population growth and economic development concerns generally are not considered pressing issues in the United States. Nevertheless, the underlying issues of population and development, such as health care, education, poverty and employment, are quite salient here at home. Indeed, these issues are at the core of the welfare and health care reform debates occurring in Congress and among the states.
High U.S. rates of unintended pregnancy, induced abortion and teenage pregnancy point to an inability-and, often, an unwillingness-to craft a comprehensive national policy aimed at helping couples avoid unplanned pregnancy and its consequences. Overall, about 60% of all pregnancies to U.S. women are unplanned, including 76% of pregnancies to poor women. In the United States, the proportion of births that are unintended is as high as or higher than it is in 25 developing countries, illustrating that women in the United States and in the developing world have more in common than generally realized.
High levels of unplanned pregnancy and unwanted births are particularly devastating for poor women and their families. Compounding the socio-economic barriers that poor women and men struggle against on a daily basis, long-standing public policies undermine their ability to control their own childbearing. While federal and state medical assistance programs pay for prenatal and maternity care for poor women, as they should, these same programs often fail to provide poor women and teens with full access to the range of family planning, abortion and other reproductive health services that would enable them to make voluntary and responsible decisions about their childbearing.
Teenage pregnancy. Compared with other industrialized countries, U.S. teenagers experience considerably higher rates of pregnancy, despite the fact that levels of adolescent sexual activity are about the same. One million U.S. teenagers become pregnant every year, 85% of them unintentionally. Half of these pregnancies end in birth, a third in abortion, and the rest in miscarriage.
Almost three-quarters (73%) of U.S. teenagers who accidentally become pregnant are poor or low-income,* even though overall only 38% of those aged 15-19 are poor or low-income. And while a significant number of lower income teenagers who become pregnant choose to have an abortion (39% of poor and 54% of low-income teenagers), a large proportion continue their unplanned pregnancies to term. Early childbearing among disadvantaged teenagers exacerbates the myriad problems they face living in poverty. Improving access to comprehensive reproductive health services is an important cost-effective strategy that would help "empower" lower income teenagers to take responsibility for their lives.
• 'Poor' refers to those whose family income is at or below the federal poverty level; 'low-income' to those with incomes between 100% and 199% of the poverty level.
Ironically, a key source of family planning services for poor and low-income women and teenagers-Title X of the Public Health Service Act-has failed to win reauthorization from Congress over the last 10 years. As a result, between 1980 and 1992, the program's funding for contraceptive services dropped 72% when inflation is taken into account. Yet every public dollar spent for family planning services saves $4.40-over $3 in medical costs alone-that otherwise would be spent over the next two years to provide medical care, welfare benefits and other social services to a pregnant woman. The bottom line: Publicly funded family planning services prevent an average of 1.2 million unintended pregnancies each year, including 516,000 abortions.
Voluntary services. In Cairo, the United States joined the call for universal access to family planning and reproductive health services for all men and women who want them. Additionally, the United States condemned all forms of coercion and incentives or disincentives with regards to family planning and reproductive behavior, endorsing the right of individuals to decide if and when to have children.
But, back at home, many of the current welfare reform proposals on Capitol Hill and in the states call for financial disincentives to discourage adolescent pregnancy and out-of-wedlock births. These proposals would prohibit financial support to poor unwed teenage mothers and their children, and would deny an increase in benefits to mothers who have additional children while on welfare. Rarely mentioned is the central role of family planning and abortion in enabling women to control childbearing. Also conspicuously absent from these proposals is recognition of men's responsibilities in family planning and childrearing. Addressing these fundamental issues is the key to fostering independence and enabling low-income women and their families to obtain the schooling and job skills necessary to become self-sufficient.
Abortion. The United States also endorsed the Cairo recommendation that where abortion is not against the law, governments should ensure that it is safe. Although abortion was legalized in the United States more than 20 years ago, the imposition of government restrictions at both the federal and state level has seriously undermined women's access to safe abortion services.
Mandatory state-scripted counseling and waiting periods, prohibitions on public funding of abortion for lower income women and mandatory parental consent or notification requirements are antithetical to sound public health policy. By impeding women's access to abortion services, such restrictions increase the likelihood that women will obtain abortions later in pregnancy, thus rendering the procedure less safe than if it were performed earlier.
By contrast, a national health policy that commits to making abortion safe and, at the same time, recognizes prevention of unintended pregnancy as central to making abortion less necessary would go a long way to improving the health and well-being of women and their families.
U.S. International Policy
For almost 30 years, population assistance has been a central component of U.S. development assistance. While much more remains to be done, population assistance has had a significant, positive impact on the health of women and their children and on society as a whole in most countries. In many parts of Asia, Latin America and Africa, fertility rates have decreased, sometimes dramatically. Couples are succeeding in having the smaller families they want due to greater availability and use of contraceptives.
Today, approximately 55% of couples worldwide use modern methods of contraception, compared with 10% in the 1960s. Despite this impressive increase in contraceptive use, the demand for family planning services is growing, in large measure due to a growing population base. Indeed, over the next 20 years, the number of women and men wanting to use contraception will almost double.
Maternal health. Similarly, population assistance has contributed to the significant progress that has been made in reducing infant and child mortality rates. Child survival is integrally linked to women's reproductive health, and specifically to a mother's timing, spacing and number of births. Despite progress to date, high proportions of women in the developing world, in particular, sub-Saharan Africa and some Asian countries, still experience the death of a child.
And, many countries in the developing world have succeeded in reducing maternal mortality rates, in spite of usually scarce resources. Nevertheless, the incidence of maternal death and disability remains unacceptably high, constituting a serious public health problem facing most developing countries. According to the World Health Organ-ization, an estimated 500,000 women die every year as a result of pregnancy and childbirth; of those, at least 70,000 deaths are due to unsafe abortion.
In Cairo, countries also recognized that, beyond contributing to improvements in reproductive health per se, the provision of health care services, particularly reproductive health, are a prerequisite for achieving sustainable economic growth. The healthier individuals and families are, the more likely they are to be productive and contribute to local development efforts. This productivity, in turn, spurs economic progress and enhances the prospects for political and social stability.
Comprehensive approach. No country delegation at the Cairo conference disputed the premise that improving the status of women-through expanded access to health care, education and employment opportunities-is key to population and development strategies. All agreed that simply distributing contraceptives was not enough, that family planning services need to be part of a more comprehensive approach aimed at addressing the full range of women's reproductive and general health needs. In supporting this broader health agenda, both donor and recipient countries pledged to increase funding for reproductive health, including family planning, over the next 20 years.
U.S. population assistance is preventive medicine on an international scale. Congress has long recognized this to be the case and over the years has reaffirmed the centrality of population and other development programs in securing U.S. interests abroad. By addressing the basic health and educational needs of women and their families, population assistance provides the building blocks for strong democratic government and sets the stage for economic growth. Further, it helps obviate social and political crises, thereby averting the need for costly relief efforts.
As Congress looks for ways to reduce federal spending across the board, development assistance-of which population assistance is a key component-is frequently mentioned as an area deserving of deep cuts. It is important to bear in mind, however, that the entire international aid portfolio accounts for less than 1% of the federal budget, thus making it an unrealistic source for significant savings. Moreover, during the last decade alone, Congress cut U.S. international assistance by one-third, leaving the Agency for International Development (AID)-the sole U.S. government agency with the mission of providing overseas development and humanitarian assistance-with an ever-dwindling budget that fails to reflect the responsibilities the United States shoulders as the lone world superpower.
Abandoning or severely weakening U.S. commitment to population and development assistance would directly undermine U.S. leadership in promoting democracy and free market economies within developing countries. The fact that the fastest growing markets for U.S. products and services are in the developing world should be reason enough not only to continue funding development programs but also to increase such funding in the future.
The Alan Guttmacher Institute (AGI), Women, Families and the Future: Women and Reproductive Health, a series of regional fact sheets, New York, 1994.
AGI, Sex and America's Teenagers, New York, 1994.
Population Action International, Financing the Future: Meeting the Demand for Family Planning, Washington, DC, 1994.
United Nations International Conference on Population and Development (ICPD), "Programme of Action of the Conference," Cairo, Sept. 19, 1994.
The preparation of this Issues in Brief was made possible with the support of the Pew Charitable Trusts/Global Stewardship Initiative.