Ana Maria Pizarro, gynecologist and Nicaraguan women’s health activist, writes that public policies toward women’s quality of life, health, and education have veered away from rights and empowerment due in large part to the erosion of the secular state.

Nicaragua’s population policy has been set out in two documents prepared by two successive governments. The first of these two documents, the “national population policy” was issued in September 1996, toward the end of Violeta Chamorro’s government. Jointly prepared by UN agencies and various government ministries, the population itself was not consulted in designing the policy.

Among those who signed the document was Education Minster Humberto Belli, a man close to the Vatican who will go down in national history for his negative influence on everything related to population polices. The document reflects the overall education policy of the Chamorro administration (1990-1996), emphasizing “education in values for family life” within the framework of moral values and family values largely defined by Nicaragua’s Catholic Church. According to statistics, 64% of Nicaragua’s population is Catholic, although only 30% declare themselves practicing Catholics.

The Liberal Party government of Arnoldo Aleman drafted another population policy in late 1997. Although the Aleman government espoused more secular views than Chamorro’s social conservative government, the Aleman policy also reflected a traditional moralistic approach. This remains the nation’s policy to date. Before analyzing that policy, it is worthwhile to look at the history of population policies in the country.

The Pro-Birth and Population Control Policies of the 1980s

The Sandinista government never wrote up a population policy, although aspects of one showed up in the leaders’ speeches. The revolutionary government took a pro-birth stance that encouraged women to have all the children they could. Latin American revolutionaries of the 1960s and 1970s opposed population control or family planning proposals, or even the use of birth control methods, on the grounds that they were feeding into a U.S. imperialist objective.

U.S. projects to sterilize poor, indigenous, and black women abounded in Brazil , Bolivia , and other Latin American countries in those decades, responding to the prevailing philosophy that population control was a means of controlling subversion. The discourse was that the more Latin American poor there are, the more guerrillas to bear arms in liberation struggles, ergo sterilize the women. The revolutionaries responded by echoing the logic but reaching the opposite conclusion: ergo, go forth and multiply.

Both the North’s population controllers and the South’s population promoters imposed decisions on women’s bodies, without knowing or caring if they agreed. The leaders of the Sandinista Front were children of that revolutionary pro-birth thinking and supplemented this “Latin American reasoning” with their own national logic: women had to bear children to replace those killed in the war. That idea was overtly present in many speeches by Sandinista leaders and seldom questioned in those years.

These two antagonistic positions dominated our continent’s panorama for many years. Latin American women were stuck between the two, with no voice in the matter and often forced into giving birth in risky conditions.

Meanwhile, traditional Catholic morality has steadfastly promoted the idea that maternity is woman’s supreme calling, as demonstrated by the Virgin Mary who silently assumed her maternal destiny. For a long time this Catholic discourse paradoxically coincided with that of left-wing revolutionaries.

The World Population Summits

These ideas prevailed in 1974, when the United Nations organized the first world conference on population and development in Bucharest. The second was held in Mexico in 1984, and the third in Cairo in 1994. Washington’s policies on population and reproductive rights heavily influenced the results of all three.

In Bucharest , population growth was seen as the main enemy. By 1984, however, U.S. philosophy had changed. Population growth ceased being viewed as a threat and began to be seen more neutrally. The U.S. military presence was so large and exerted such a degree of control that the issue of population growth lost relevance for U.S. strategists. Sterilization campaigns and promotion of birth control methods began to wane.

Ten years later, in 1994, First Lady Hillary Rodham Clinton influenced the Clinton government to assume a modern vision that included some respect for women’s rights. Nonetheless, the president was surrounded by people still interested in population control who shrewdly adopted a new twist–the concept of “family well-being.” Throughout Latin America, organizations sprang up to push the idea of family well-being and the image of the ideal “happy family”–a father, a mother, one boy, and one girl. By the end of a decade marked by a massive redistribution of wealth to the rich and the accompanying growth of poverty in Latin America , the “happiness” concept had been downplayed and emphasis shifted to well-being ensured by having only one child.

As birth control once again spreads all over Latin America, population control discourse and involuntary sterilization have been transformed into the more upbeat notion that a couple’s decision to reduce the number of children ensures family well-being by reducing poverty. Over the years, countries such as Mexico and Brazil have managed to drastically reduce the net number of children per woman through family planning campaigns.

But doing so has not reduced poverty or brought about family well-being, because poverty is not reduced and well-being is not achieved by controlling women’s bodies and reproduction.

New Concepts: Sexual and Reproductive Rights

The 1994 Population and Development Conference in Cairo opened the door to more progressive ideas on reproductive rights. The documents from that conference explicitly recognize the inequity of the global distribution of wealth. Extraordinary advances were made in Cairo, favored by the strong U.S. stance on human rights.

Two key concepts appeared in that conference: sexual rights and reproductive rights. The international community achieved broad consensus around these ideas in Cairo. But that consensus is under assault, and both concepts remain at the center of ideological debates currently raging in Nicaragua.

Only eight participants did not sign the Cairo declaration: Argentina, Nicaragua, El Salvador, Honduras, Guatemala, Ecuador, Malta, and the Vatican. The Vatican has observer status in the UN, which gives it the right to be present at all conferences without voice or vote. Despite its observer status, the Vatican exerts tremendous influence and has ways of making clear its reservations about proposed texts and demands for changes. How? Basically, it functions as a powerful lobby by getting the delegates of countries under its sway to speak for it. Vatican representatives often call the bishops of those countries to point out the problems, who in turn pressure the country’s president to instruct conference delegates on what to say and how to vote. We saw this happen time after time in the processes that culminated in both the Cairo population conference and the conference on women in Beijing. The operation typically takes all of about an hour.

Many Latin American delegates to the world conferences have had dubious credentials for representing their countries. Some delegates were first ladies or officials selected because they were Catholic “mothers” or “fathers,” poorly qualified to discuss political and economic affairs, laws, decrees, or budgets. Often the documents coming out of these conferences are drafted by people with extremely high technical capacity, then influenced on many points by the bishops and other religious representatives who attend to control their country’s official delegates. I have personally witnessed delegates being sent back to their country for daring to defend human rights and the secular nature of the state, and for speaking up about sexuality and reproduction in what these religions lobbyists considered an “undue” manner.

The debate in Cairo was especially arduous. Nicaragua headed up Central America’s representation of Vatican interests. Two figures were particularly influential: Education Minister Humberto Belli, and his adviser on values, Elida de Solorzano. Elida de Solorzano recently formed a women’s NGO called Nicaraguan Women’s Association (ANIMU). Since 1993, she has represented the Nicaraguan government in all UN conferences on population and on women. I still recall with amazement how in one international preparatory meeting for Cairo, she publicly called the international director of the UN Population Fund an “abortionist.”

How Secular Is the Nicaraguan State?

Article 14 of the Nicaraguan Constitution establishes a secular state with no official religion, Article 68 establishes that “no-one can elude observance of the laws or impede others from exercising their rights and fulfilling their duties by invoking religious beliefs or dispositions.” But recent events related to women’s health indicate that these constitutional guarantees are not being fulfilled in Nicaragua.

Recently, the Education Ministry published a manual entitled “Education for Life.” Developed with support from the UN Population Fund, the manual was to be distributed to teachers around the country as a tool for sex education in the schools. Protest from religious sectors was so strong that President Bolaños was forced to withdraw the manual from circulation, stating that the manual must “reflect our values, our customs, our philosophy of life, and the Christian nature of its ethical and moral principles.”

This was the second public document to be censured based on religious criteria. On Jan. 31, 2002–just weeks after Bolaños took office–the Ministry of Health presented a document entitled “For a national sexual and reproductive health program in the health sector reform.” Although the document was drafted by the government and UN agencies without input from civil society organizations, many of us felt it contained important positive aspects.

In less than a month, however, the Ministry recalled all copies. A World Bank-financed official then took it to the Bishop’s Conference for consultation. A few months later, a new text appeared called “National reproductive health program.” The word “sexual” had been cut, as had any reference to sexual and reproductive rights in the introduction. The “revised” document does not recognize these rights.

The Crisis in Women’s Health

The document does contain an assessment of women’s health in the nation and recognizes the extremely serious problems that exist. Maternal mortality in Nicaragua is “high,” although it provides no precise statistics. Another official document released at the same time, the “Enhanced Economic Growth and Poverty Reduction strategy” puts the figure at 148 per 100,000 live births–one of the highest rates in Latin America. But since we are a country where no statistic is remotely reliable, an epidemiological bulletin posted on the Ministry of Health’s web page claims this same rate as 93 per 100,000, while UNICEF uses the figure of 250 per 100,000.

The reproductive health document profiles the women most likely to die as a result of pregnancy or childbirth. They are young, with little or no education, poor or extremely poor, and live on the outskirts of cities or in rural areas. Experience tells us that the prime cause of maternal mortality at a national level is post-delivery hemorrhaging, particularly in rural areas where women give birth at home, attended by other women with inadequate training. In hospitals, the main causes of maternal death are complications resulting from abortions practiced in clandestine conditions and eclampsia–high blood pressure with convulsions linked to parturition or postpartum.

Twenty-seven percent of all female Nicaraguan adolescents are either pregnant or have given birth. This is the highest adolescent fecundity rate in all Latin America. For every 1,000 female adolescents between 15 and 19 years old, 139 are pregnant. Thirty percent of the maternal mortality victims are under 19 years old. This demonstrates that many of our adolescents are getting pregnant, dying, or aborting in complete abandonment.

In a study we did in 1998 in five Nicaraguan hospitals, we found that 150 women had been admitted due to abortion or miscarriage, 32% under 19. The issue of teen pregnancy is in vogue now, but no government institution wants to talk about teenage abortion. The reality is that female adolescents who have sought abortions in clandestine, unsafe conditions are filling the hospital wards. The director of the Bertha Calderon Women’s Hospital recently reported that botched abortions were filling half the obstetrics beds. He complained that the much of the hospital budget is being spent to save the lives of young girls who have had an abortion. The University of Leon puts the number of high-risk abortions at close to 80,000 a year.

Nicaragua’s annual health budget for 2003 is the equivalent of only U.S.$22 per person. In a situation of shortage, hospitals are spending thousands of dollars treating complications from teenage abortions. Perhaps by showing the economic costs involved, we can introduce some measure of rationality into debate on this vital and sensitive issue.

Whose Job Is Sex Education?

One can only hope that the adolescents who find themselves in the hospital following an unsafe abortion–those who didn’t die beforehand–have families they can talk to so they don’t have to get their information on the streets. But very few families educate their sons and daughters on sexuality, because they never received information themselves and don’t know how to do it. This is why formation and information must be a government responsibility.

Nicaragua doubles its population every 20 years. At this rate, in twenty years we will have a population of at least 10 million. Yet we can be sure we will not have doubled access to education and health care, much less narrowed the gap between the huge number of Nicaraguans who are extremely poor and the few who are extremely rich. That gap means that we have one of the most unequal societies in the world and a minimal middle class. According to the latest Human Development report by the United Nations Development Program, 82.5% of Nicaragua ‘s population survived on the equivalent of only one dollar a day over the past four years.

Other areas of women’s health reflect the problem of access to care. Despite the fact that worldwide most cases of cervical cancer occur in women over 40, in Nicaragua 45% of cases are in women between 20 and 35. The Ministry of Health only does the Papanicolau test, which costs about $3, to detect this type of cancer on 10% of the country’s female population, This means we do not know the real situation of the vast majority of Nicaraguan women.

Time to Fight AIDS–Before It’s Too Late

Finally, we have been told for years that for some mysterious reason Nicaragua does not have as many AIDS cases as other countries. But there is reason to suspect that there are many more cases that go unreported. The Ministry of Health currently has registered 1,060 cases. Even Nicaragua ‘s very low reported epidemic began to rise last year: from a reported rate of 1.8-1.9 for every 100,000 to 3.2. This means that in a year we could reach 5 per 100,000–considered the point when an epidemic is no longer controllable.

Nicaragua has allowed itself the luxury of wasting time since 1987, when a peasant became the country’s first detected carrier. The government proposed moral values as substitutes for condoms and counseled sexual abstinence, self-control, and self-discipline as safer methods than massive information campaigns and distribution of condoms. We can no longer be so complacent; we have little time before reaching the catastrophic prevalence of 5.

The government bought medication for just 18 carriers of the virus, and then only after the Inter-American Human Rights Commission ruled in favor of their right to treatment and ordered the government to purchase medicines for them. The government then bought only three months worth of antiretrovirals. But these cause a rebound effect when the patient stops taking them so it is better never to take them than to discontinue use. I belong to CONASIDA, the Nicaraguan AIDS Commission, so I know that not a single cent was programmed to treat AIDS patients and buy medicines for them in 2003.

According to the official assessment, women make up 23% of those affected by AIDS in Nicaragua. But this statistic rises to 44% of those affected between the ages of 15-19. Again, female adolescents are especially vulnerable, but this fact has merited no attention from the health or education ministries. It is expected that the number of children born with AIDS will increase given the fecundity of infected women–99% of women with AIDS are of fertile age. These women have already given birth to 700 children and it can be calculated that 40% were born HIV-positive. During the Aleman administration, the Health Ministry under Mariangeles Arguello issued propaganda about its program to provide AIDS treatment to three pregnant women to avoid vertical transmission to their children. When it had been ascertained that the babies were AIDS-free the treatment for the mothers was immediately suspended.

Domestic Violence–An Unspoken Public Health Problem

In 1996, at the height of the electoral campaign, the Chamorro administration issued a ministerial decree recognizing domestic violence as a public health problem. This decree stands alongside Law 230 that established domestic violence as a crime and set sentences to punish it. With these two legal instruments, the Ministry of Health should have addressed intra-family violence against women and children but seven years later the decree still exists only on paper.

Domestic violence is a genuine epidemic in Nicaragua . According to ENDESA, an official demographic and health survey, 29% of the 16,000 women interviewed nationally declared that they had been the victims of violence at some point in their life and of those 37% were hit by their partners while pregnant. In 53% of the child sexual abuse cases the aggressor was a family member. This data further underscores the need for a massive public sex education policy in Nicaragua.

Government Initiative Spurs Protest

All this evidence triggered the publication of the education Ministry’s manual “Education for Life.” The manual addresses self-esteem, human rights, self-respect, the human body, emotions, affection, love, sexual relations, prevention of sexually transmitted diseases, and prevention of pregnancy. One of the main objectives was to prevent the risks and undesired consequences of sexual relations.

Much of the text is designed to help young people separate sex from love. Due to lack of reflection, young women frequently seek to “prove their love” by agreeing to sexual relations when young men are merely seeking sex. Educating around that fundamental distinction would help resolve many of the health problems that crop up daily in Nicaragua.

The manual’s contents were discussed with officials in the Health, Education, and Defense ministries, the Youth Secretariat, the Women’s Institute, and other institutions. Some 40 national officials were consulted. Powerful groups opposing the manual have labeled these civic leaders as libertine, lacking ethics, and promiscuous. Their attacks led to the decision to withdraw the manual.

The manual was the first sign that the government intended to assume its responsibility for the dramatic situation in reproductive and sexual health. Just as we began to see progress, religious interests, both Catholic and Protestant, rose up to protest. These symbolically powerful groups succeeded in imposing their viewpoints with no legal or constitutional evidence.

Among those belligerently opposed to the manual are the Catholic hierarchy and individuals heading Catholic groups, prominent among them Elida de Solorzano and Humberto Belli. These groups and individuals objected to the manual, arguing that the state was usurping the right to educate on values that only the family should transmit. Belli argued that the manual’s content belongs in the private sphere and that parents should educate their children according to their own values, without state intervention. This idea would perhaps be valid if we were living in a very developed society with a high educational level and citizens who have had the opportunity to develop their own informed criteria and are very guarded about the state interfering in their private lives. But in Nicaragua, where the state has never been involved in education for life, it is rather strange for a former education minister to be questioning why the state has to educate.

Two of the most belligerent opponents of the manual from the Protestant side are Rev. Roberto Rojas and his wife, Elizabeth de Rojas, leaders of the Assemblies of God–the largest Protestant denomination in Nicaragua and founders of the “Evangelical Alliance.” They have repeated on many occasions that “37,000 children are murdered annually in the women’s centers.” The figure, cited in the Chamorro population document, actually refers to the estimated number of clandestine abortions performed in Nicaragua each year.

Nicaragua ‘s Penal Code and the “Right to Life”

Nicaragua’s Penal Code contains more violations of the constitutional principle of separation of church and state. Although it has been reformed several times, the penal code dates back 130 years. A new code has been drafted and approved in general by the National Assembly. The final step is an article-by-article debate and passage.

Article 146 of the new code retains the legality of therapeutic abortions from the old law, but a new legal concept appears in Article 148 that requires a detailed explanation.

In 1999, Argentine President Carlos Menem was in the apogee of his relations with the Vatican, which had just decorated him with the Order of Saint Gregory the Great–the order that the Vatican bestows on laymen and lay women it considers defenders of human rights, generally defined as anti-abortion activism.

Menem was the Vatican ‘s most militant crusader in the Cairo +5 process to revise the original Cairo document five years after the conference. Anti-abortion groups tried to substantially modify Cairo ‘s progressive agreements and Menem took an active part in opposing all mention of reproductive and sexual rights. After receiving the order, he began work on the Vatican agenda to establish legal rights for the unborn in Argentina .

The Vatican seeks laws to confer full citizen status on fetuses from the moment of conception. This sets up a contradiction: The constitutions of countries all over the world grant rights only to persons already born and these “new” rights would conflict with the rights of many people already born, especially women.

The Vatican has exploited the state reform process imposed by international financing agencies in Latin American to establish this new agenda. The first proposal set forth by the Vatican is to proclaim March 25 the “Day of the Unborn.” This date commemorates the announcement of the Incarnation to the Virgin Mary, according to the liturgical calendar. President Menem duly proclaimed “Day of the Unborn” in Argentina in 1999. Nicaragua’s President Aleman followed suit the following year. The “Day of the Unborn” has also been decreed in Bolivia , the Dominican Republic , Guatemala , and Costa Rica .

Under the same logic, Article 148 of the new penal code is titled “on injury to the as yet unborn.” It sets out punishments for doctors who cause physical or psychological injury to the fetus during the nine months of gestation. Punishment includes five years in prison, 8 years of absolute prohibition from practicing medicine, and 8 years of closure for the clinic or consulting center involved. Nicaraguan medical practitioners have yet to react. It seems they have not thought through the consequences of having one article that authorizes therapeutic abortions and another that penalizes injury to the unborn.

Article 148, still pending approval, is another expression of the church’s incursion into the legislation of a secular state. Something similar already exists in Colombia’s new penal code. A group of Nicaragua politicians from the Conservative Party has tried to go even further by proposing to reform Article 23 of the Constitution that affirms respect for “life” by tacking on: “from its conception to its natural end.”

The Nicaraguan state is officially secular, but many officials and powerful sectors of our society seem unwilling to respect this constitutional principle. Because of this, we have to continue to reflect and act to make the separation of church a state a reality. Only by studying, reading, and documenting what is happening will we be able to effectively contribute our opinions to this debate. The gravity of the country’s health situation and the lives of thousands of women and girls requires that we add our wise Catholic and non-Catholic voices to this debate and effort.