Ethiopia: Women struggle, but strings bind U.S. help
Lalibela, Ethiopia - It's Sept. 11, Ethiopian New Year's Day. A procession of priests in white robes and turbans has emerged from 800-year-old churches carved from a single rock. They're parading the streets in this highland town, drumming and dancing in celebration.
The air is clean and pregnant with possibilities, the setting a breathtaking backdrop of green cascading mountains dotted by goats. Children gather to banter and laugh with foreign visitors.
This is Ethiopia at its best: pure, joyful, engaging - and gorgeous. Uncorrupted by fast food, trash TV and materialistic values, free of the pervasive, cynicism-breeding commercialism of the Western world.
It's where a drive through the highlands might include an encounter with a fleet of monkeys and baboons fleeing down a mountainside. Just miles ahead, you might run across a flock of majestic camels being herded through the street. Approaching a town's center brings the whimsical sight of a group of kids playing at a foosball table by the roadside.
It's where beautiful women fill the urban health clubs and eateries, and some sigh that with so much competition, they have no hope of husbands being faithful.
But there is another side to Ethiopia. It's where a girl of 16 tells of having been married off at age 10 to a man more than twice her age, and fleeing a few years later. And where other young women fear going to school because of the chance they'll be abducted on their way home, then raped and forced to marry their abductors because they are no longer virgins. Perhaps 20 percent of marriages were forged that way, some activists say.
And it's where poverty and malnutrition are so rampant that it's not shocking to hear a young mother talk of having lost four babies because her own milk dried up and she couldn't afford to pay for any. More than one in 10 children dies before age 5. Some who survive are put in charge of cattle as youngsters. Or the girls are married off. Or, as in the case of an adorable, shy boy growing up in the Lalibela Hospital, they're abandoned after being brought in for treatment.
It's where a group of village women pauses from sharing coy laughs about intimacies and confesses that sex brings no pleasure. That potential was eliminated along with the most pleasure-giving part of their bodies in ritual surgical removal of the clitoris when they were babies.
It's where 1.5 million people are currently HIV positive and where nearly that many children have lost at least one parent to AIDS, some estimates say. AIDS has lowered life expectancy to age 49 for men, age 51 for women.
Simple and complex, Ethiopia is a country easy to fall in love with, but likely to break your heart. It also offers a window on a continent where U.S. aid policies play a disproportionate role in determining people's futures.
The trip I took was organized by EngenderHealth, a U.S.-based nongovernmental organization that supports and trains health providers in family planning and AIDS prevention through programs in Ethiopia and elsewhere. Tour organizers led six U.S. delegates through clinics and hospitals EngenderHealth works with, and organized meetings with health and community leaders in population planning.
United States donates millions
Just as Ethiopia is a mixed bag of positives and negatives, so is the U.S. aid program there. America is Ethiopia's single largest aid donor. It spent $147 million there in 2005 on basics such as food, economic development and children's health. It targeted an additional $84 million there for AIDS prevention and treatment. Also invaluable are the work of nongovernmental organizations that fund and run family clinics and unofficial ambassadors like Oprah Winfrey, who has raised global awareness about child marriage and a humiliating childbirth condition called obstetric fistula.
Yet some of our government's generosity is compromised by restrictions driven not by that country's needs but an ideological agenda back home. It's one thing, for example, to require U.S. schools to teach only abstinence until marriage in publicly funded sex-education programs. But Congress, in extending its faith-based initiatives overseas, also has mandated that at least a third of AIDS-prevention money abroad be spent on promoting abstinence programs. When we place that caveat in a country where girls marry as young as 8 or 9, and 94 percent of girls having sex are married, what does pushing abstinence before marriage accomplish? And neither an abstinence oath nor the requirement that organizations getting AIDS-fighting money take anti-prostitution pledges is going to help stem the epidemic among commercial sex workers, whose only means of sustenance is selling their bodies.
While AIDS in Africa has become the focal point of U.S. aid efforts, some Ethiopian leaders say that concern has set back other crucial priorities such as family planning. U.S. support for that, too, is undermined by unnecessary restrictions, those in the field say.
Rural population booming
Why is birth control so important in a developing nation like Ethiopia? Leaders say overpopulation threatens everything from flood-recovery efforts to education to poverty eradication.
At 75 million, Ethiopia's population has nearly quadrupled in just 40 years, according to Sahlu Haile, senior program officer with the Packard Foundation in Ethiopia. Forests are depleted, fields are over-cultivated and soil is eroded, making the land more vulnerable to severe flooding three times a year. Schools are adding 30 million classes a year, packing 80 to 120 children into a classroom. "Even by African standards, our education system is the poorest," Haile said.
The majority of population growth is in the highlands, where families have an average of 5.5 children but can have up to 10 or 12. The rural population explosion has forced people from highlands to urban centers, increasing urban poverty and sprawl. It's not surprising to see people sleeping on the roadside in Addis Ababa's marketplace. And because all the food being grown is consumed, Haile said, "We're not saving." Only 18 percent of Ethiopian women have ever used any contraceptive method, according to a 2005 survey funded by the U.S. Agency for International Development. Comparatively, 61.9 percent of U.S. women of reproductive age reported using contraceptives in 2002, according to a government survey. The Ethiopian government has set an ambitious goal of 60 percent contraceptive prevalence by 2010. That's progress from a government that two years ago publicly declared that family planning wasn't needed in Ethiopia and that AIDS wasn't a problem.
But the barriers to family planning are many, including a severe shortage of health care workers. There's only one doctor for nearly 40,000 people in Ethiopia (compared with one for 400 in the United States), and even those are being recruited abroad, where they can make many times their $150 monthly earnings. There's also a lack of access to information, services and supplies. And there are cultural and religious taboos, and plain, old-fashioned sexism.
"Some husbands say if a woman takes contraception, she can enjoy herself (with other men) rather than her husband," says Hailu Berhanu, the medical director of Lalibela Hospital, which offers family planning and delivers babies. To reach the hospital, which has only two doctors and seven nurses serving 25,000 patients, people have to travel up to 75 miles on foot. So the hospital is training community outreach workers to go house to house.Wmen often have to use birth control covertly, and even getting access to water can be a problem, so many prefer long-term methods such as quarterly injections over daily pills or diaphragms.
An Ethiopian woman is "a machine who's fabricating an assembly line until the end of her fertility," says Tilahun Gilday, director of Pathfinder International in Ethiopia, another nongovernmental organization working in reproductive health.
Gag rule limits options
Family-planning professionals say America's so-called global gag rule has cut supplies of donated contraceptives, forced clinics to close and even compromised screening and treatment of HIV. Also known as the Mexico City Policy, it stipulates that any foreign organization getting U.S. family planning money must agree in writing not to perform, counsel, refer or advocate for abortion services, even in rape or incest cases, and even with money from other sources.
When Ethiopia's largest independent provider of family-planning services, the Family Guidance Association, refused to sign the gag rule, said Amare Bedada, its executive director, his organization lost one of its two major suppliers of contraceptives, particularly the long-acting Norplant, which is in high demand in Ethiopia. It also lost a quarter of its funding from International Planned Parenthood Federation, which also had to forfeit money from the U.S. AID. The Family Guidance Association had to shut down outreach services in rural areas, leaving women to walk 30 miles or more.
"We haven't counted the number of women who got pregnant as a result," Bedada said. Marie Stopes International in Ethiopia, which provides post-abortion care as well as abortions allowed under Ethiopian law, also refused to sign. Ironically, U.S. AID will fund post-abortion care to finish off the crude work begun by underground practitioners. As a donor, of course, the United States can set whatever terms it chooses. But if the providers of family planning can't offer access to contraceptives, more women will end up pregnant, and some will try to abort, legally or not. That also increases maternal deaths, because unsafe efforts to end pregnancies can result in death.
And the leaders of nongovernmental organizations complain that the gag rule is undemocratic because those who provide the services in Ethiopia were not allowed to weigh in about how best to serve their populations. Though Ethiopia's government recently added exceptions to its anti-abortion law, there is also concern that if the international donors don't allow any abortions, medical practitioners won't perform them even when the law permits.
AIDS testing hamstrung
Another place where U.S. donor policy conflicts with realities on the ground: The President's Emergency Plan for AIDS Relief stipulates that money to fight AIDS not be spent on any other medical service, such as family planning. That so-called vertical-funding mechanism means that services can't be offered by the same program, in the same place, though providers say integration is critical to get the most services to the most people. It's more cost-effective and convenient when clients can go to the same clinic for HIV testing and birth-control services. And it's less stigmatizing to get an AIDS test when it's done at a multiservice clinic rather than a free-standing one just for AIDS. Also, those who come in for family planning can be educated about HIV prevention and vice versa.
The Bush administration also has for five years denied funding to a key ally in the reproductive health field, the U.N. Fund for Population Activities, because of a claim, which our government's own investigators found to be groundless, that it supports forced sterilizations in China. And the U.S. Senate's failure to ratify the U.N. Convention on the Elimination of All Forms of Discrimination against Women, which considers child marriage a human-rights violation, removes one more piece of leverage our government could have on the international arena.
Ethiopia, whose per-capita income is $160 a year, is a country where a little investment can go a long way. It's a country full of promise but long on critical needs. Lately, Ethiopia has assumed some strategic importance to the United States because it has a strong, stable government and is surrounded by countries that have active terror networks, according to the Bush administration. But quite apart from its strategic value or promoting an ideological agenda, Americans ought to care about Ethiopia for Ethiopians' sake - and to ensure that our efforts there help them to thrive.