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In search of human dignity: gender equity, reproductive health and healthy aging
International Journal of Gynecology & Obstetrics 59 Ž1997. 195]206
Special article
In search of human dignity: gender equity, reproductive health and healthy aging Egon Diczfalusy Karolinska Institutet, Stockholm, Sweden Received 8 September 1997; accepted 26 September 1997
Abstract This paper analyzes the nine pillars of human dignity Žsufficient food, potable water, shelter, sanitation, health services, healthy environment, education, employment and personal security., which humankind tries to establish by following nine approaches to reality Žscientific, cultural, religious, ethical, economical, ecological, socio-critical, philosophical and political. in a world drastically changed by nine re®olutions Ždemographic, scientific, technological, communication, global identity, environmental, contraceptive, reproductive health and gender equity.. The author’s generation participated in these revolutions and contributed to the global intellectual process by which gender equity and reproductive health assumed a central role in world affairs. A rapidly aging world population constitutes another major challenge. Its likely impact on the very fundaments of our future social, economical, health and even political infrastructures is } as yet } incompletely comprehended by the international community. The International Federation of Gynecology and Obstetrics ŽFIGO. has and will continue to have an indispensable role in assisting humankind to reach its ultimate goal : human dignity. Q 1997 International Journal of Gynecology and Obstetrics
The following is the text of the Hubert de Watte®ille Memorial Lecture, presented by Professor Egon Diczfalusy in honor of Professor Hubert de Watte®ille, the first president of The International Federation of Gynecology and Obstetrics (FIGO), at the XV FIGO World Congress of Gynecology and Obstetrics in Copenhagen, Denmark in August 1997. Professor de Watte®ille was an extraordinary and ®isionary indi®idual who had an enormous impact on the specialty of obstetrics and gynecology. Under
the personal guidance of Professor de Watte®ille, the International Federation of Gynecology and Obstetrics (FIGO) was founded in 1954 in Gene®a, Switzerland, with Professor de Watte®ille as the first president. Four years later, at the Second World Congress held in Montreal, Canada, Professor de Watte®ille was named Secretary General of FIGO, with the Secretariat being established in Gene®a, where it remained for approximately 25 years. Professor de Watte®ille’s dedication and enthusiasm,
0020-7292r97r$17.00 Q 1997 International Federation of Gynecology and Obstetrics PII S0020-7292Ž97.00230-0
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coupled with his limitless energy and international contacts, lent great strength to the Federation in those de®eloping years. His legacy carries on in the FIGO world congresses and in the e®er-increasing role of FIGO in international obstetrics and gynecology. It is also noteworthy that Professor de Watte®ille was instrumental in the formation of the International Federation of Fertility Societies (IFFS) and ser®ed as president of that multinational group. Following Professor de Watte®ille’s death in 1984, the executi®e boards of FIGO and IFFS collaborated in establishing the Hubert de Watte®ille Memorial Lecture series. At the triennial world congresses of each organization, a de Watte®ille Memorial Lecture is presented. The lecturer is selected by a committee composed of past presidents from both organizations.
1. The human condition: darkness and light
This is the last FIGO Congress of the century and even of the millennium. To deliver the Hubert de Watteville Memorial Lecture on an occasion like this, is not only a great honor, distinction and particular privilege; it is also a major responsibility. Why? Because we are living in difficult times. Well, are not all times difficult times? How did Waldo Emerson say in 1864? ‘These times of ours are serious and full of calamity, but all times are essentially alike’. So, what is the difference? The difference is the rate of change. ‘The rate of change is outstripping the ability of scientific disciplines and our current capabilities to assess and advise’, stated the World Commission on Environment and Development in 1987 w1x. Indeed, the changes around us are accelerating, but our perception of these changes and of their consequences is lagging more and more behind... In times like this, it becomes of crucial importance to have a vision of the future. However, I am convinced, that only those with some knowledge of the past can have a vision of the future. ‘Es bueno vivir mucho para ver mucho Žit is good to live long in order to see much.’, says
Sancho Panza in Don Quijote Ž1620., and I have witnessed most of the history of the 20th century. When I was born, the global population was less than 2 billion people; next year it will exceed 6 billion. Hence, in my lifetime, I have seen the birth of another two worlds, equal in numbers, needs, aspirations, hopes and dreams. Indeed, I have seen much. Perhaps even too much... Schopenhauer remarks in his Parerga und Paralipomena Ž1851., that ‘the man who sees two or three generations is like someone who sits in a conjurer’s booth at a fair, and sees the tricks two or three times; they are meant to be seen only once’. I have seen the tricks of the political ‘magicians’ of three generations. I have seen their flirtation with the apocalypse in the shadow of the hydrogen bomb and I have frequently seen the two powerful determinants of human destiny: the arrogance of power and the arrogance of ignorance. Then Sancho Panza continues: ‘El que larga vida vive mucho mal ha da pasar Žthose who live long also pass through much evil.’ and I have seen a fair amount of it, witnessing the history of a century in which some 200 million human beings were killed } frequently in a deliberate and systematic fashion } by other human beings, on orders of the ‘magicians’. I have seen plenty of the dark aspects of what we call ‘human nature’, be it violence, aggression, barbarity, terror and cruelty, hypocrisy, moral and intellectual corruption and naked cynicism and I have learned, like Publilius Syrus did 2000 years earlier, that ‘cruelty isn’t softened by tears; it feeds on them’. However, as Alexander Pope said Ž1735., ‘there must be shadows, if there should be light’ and I have also seen an incredible amount of light. In my lifetime, I have seen more progress in science and technology, than all scientists of all preceding periods together, since the dawn of history. The reason for this is simple mathematics; as it was observed by Friedrich Engels ‘science progresses in proportion to the mass of knowledge that is left to it by preceding generations, that is under the most ordinary circumstances in geometrical proportion’. I have also seen nine major revolutions, as indicated below.
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2. Nine revolutions I have witnessed Žand frequently participated in. nine powerful revolutions, that have profoundly changed our world and our perception of it. According to the Oxford English Dictionary, the word revolution has multiple meanings; it may mean movement round an axis, the movement of certain celestial bodies, a complete overthrow of a government, or a great change in affairs or things, and I use the word in this latter context. The nine revolutions of my time Žas I perceive them today. were those shown in Table 1. Only a few of them require any comments. The revolution in communication is, of course, part of the technological revolution. I list it separately, however, since it assumed a commanding role in human affairs in a world where the medium became more important than the message. The revolution of global identity is perhaps the most characteristic change of the 20th century. It is true that our world has never been more integrated and more fragmented at the same time; however, this development Žlike all developments. must be viewed in a broad historical perspective. Indeed, the 20th century was the first time in history when humankind dared to establish the United Nations with its numerous Specialized Agencies, like the World Health Organization and with hundreds of international professional associations, some of them, like FIGO, immediately making a major global impact. Also, the 20th century was the first time when humankind felt capable of providing large-scale help and Table 1 NINE REVOLUTIONS DEMOGRAPHIC SCIENTIFIC TECHNOLOGICAL COMMUNICATION GLOBAL IDENTITY ENVIRONMENTAL CONTRACEPTIVE REPRODUCTIVE HEALTH GENDER EQUITY
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assistance to those stricken by famine, or natural catastrophes in any corner of the world, and we are only at the very beginning of this irreversible process. The general acceptance of our global identity led then to the environmental revolution, the recognition of the fact that our environment is perhaps the most precious thing we have in common. When I was young, the concept of the environment simply didn’t exist; there was only ‘Mother Nature’, as we perceived it, with the self-evident role to provide in an unlimited manner all our material needs, including the disposal of any amount of waste generated by the human race on a rapidly increasing scale. The last three revolutions shown in Table 1 were intellectual ]technical in nature, sequential and truly global in character. They will have a major impact also on the history of the 21st century. These three revolutions will be discussed briefly below. 2.1. The contracepti®e re®olution The credit should undoubtedly go to the Government of India for establishing in 1952, for the first time in history, a national family planning program. This was done boldly and with courage at a time when no modern contraceptives Žoral pills, intrauterine devices. were as yet available and the international atmosphere was explicitly hostile to family planning. Of course, one may wonder, whether there ever existed an ‘international atmosphere’ that was not hostile to any new idea. At any rate, the example of India was rapidly followed by other countries and today some 150 governments support, directly or indirectly, family planning programs. The introduction of oral contraceptives and intrauterine devices in the late 1950s and early 1960s resulted in a quantum leap in contraceptive prevalence, as shown in Fig. 1 w2x. Whereas in 1960, the number of contraceptive users in the developing world was around 30 million, by 1990 their number exceeded 380 million w3x. Around 1990, worldwide contraceptive prevalence was 57%; it was highest Ž79%. in Eastern Asia and lowest Ž18%. in Africa w4x.
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Fig. 1. Increase of contraceptive prevalence in the world between 1960 and 2000. Source: WHO w2x.
Viewed globally, by the year 2000, tubectomy will remain the most widely used method Ž207 million users., followed by intrauterine devices Ž125 million. and oral, injectable and implantable steroidal contraceptives Žalmost 100 million., vasectomy Ž47 million., condom use Ž35 million. and a variety of traditional methods, with an estimated 57 million users w5x. Whether today, with more than 0.5 billion contraceptive users the contraceptive revolution still should be considered a revolution, or just a generally accepted daily routine, that improves the quality of life of 1 billion human beings, is a matter of opinion. It can be taken for granted, however, that contraception has come to stay.
health appears from the global estimates of reproductive ill-health. According to recent estimates by WHO, some 120 million people still have unmet family planning needs; some 130 million women have been subjected to genital mutilation; there are some 60]80 million infertile couples; at least 20 million adults are living with HIVrAIDS and 2 million women with invasive cervical cancer w8]10x. Annually there are some 330 million new cases of sexually transmissible diseases, 20 million unsafe abortions and the same number of cases with severe maternal morbidity. The under-5-year mortality is around 12 million and there are some 7 million perinatal deaths. Each year some 25 million infants are born with low birth-weight Ž17% of the total.. Annually, there are almost 3 million new cases of HIV infection, 2 million cases of female genital mutilation, 0.5 million new cases of cervical cancer and some 600 000 cases of maternal mortality, the majority of which could be prevented. How did Andre ´ Malraux say? ‘A human life is worth nothing; but nothing is worth a human life’. Are the governments of this world really doing their utmost to prevent maternal deaths? And the international community? It is heartening to see that FIGO is not willing to accept this state of affairs and is launching at its XVth Congress the ‘Save the Mothers’ initiative. Because of limitations of space, only some aspects of reproductive health can briefly be considered below.
2.2. The re®olution in reproducti®e health Contraception is an extremely important dimension of reproductive health, but only one of several dimensions. The credit should go to the World Health Organization ŽWHO. for initiating the revolution in reproductive health with a position paper w6x presented to the United Nations International Conference on Population and Development ŽICPD; Cairo September 1994. and also to ICPD for adopting the WHO document as the cornerstone of the United Nations ŽUN. action program in this field w7x. The overwhelming importance of reproductive
2.2.1. Maternal mortality and abortion There is indeed a tremendous scope to reduce maternal mortality and morbidity. In 1990, maternal mortality was as low as seven per 100 000 live births in Spain, or Hongkong and as high as 1400r100 000 live births in Ethiopia, or 1600r100 000 live births in Somalia. What do such figures mean? They indicate that the lifetime risk of a woman of dying from pregnancy-related causes is 1:7 in Somalia and 1:9200 in Hongkong w9x. Who is willing to accept such a situation when humankind enters the 21st century? Certainly not FIGO
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More than 11% of the 585 000 maternal deaths annually are attributable to unsafe abortions, most of them in Asia and Africa w2x. Abortion laws are markedly different around the world: whereas the laws of 173 countries accept abortion to save the life of a woman, only 119 accept it to preserve her physical health and only 95 to preserve her mental health. Rape or incest as an indication is accepted by 81, fetal impairment by 78 and socioeconomic reasons by 56 countries. Abortion is available upon request in 41 countries w16x. It would appear that, in general, the abortion laws in developing countries are more restrictive than in developed countries, as indicated by the data of Table 2 w11x. The international debate over abortion issues has always been emotional, sometimes even passionate, and, more often than not, it generated more heat than light. In my own view, the position taken by President Clinton carries a great deal of weight: ‘We believe abortion should be safe, legal and rare’. 2.2.2. Sexually transmissible diseases (STDs), including HIV r AIDS WHO estimates that among the more than 330 million new cases of STDs that occurred in 1995, there were some 89 million chlamydial, 62 million gonococcal and 12 million syphilitic infections, in addition to some 170 million cases of trichomoniasis. Chlamydia, gonorrhea and syphilis are frequently associated with a high prevalence of infertility and might increase the risk of sexual transmission of HIV infection w9x. Table 2 Grounds on which abortion is permitted in developed and developing countries Indication
To save the life of a woman To preserve her physical health To preserve her mental health Rape or incest Fetal impairment Socioeconomic reasons Available upon request Source: Van Look w11x.
Percentage of countries Developed
Developing
94.4 88.9 88.9 86.1 83.3 80.6 55.6
86.2 46.0 32.2 23.0 21.8 8.0 4.6
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Fig. 2. Increase in the incidence of syphilis in the Ukraine between 1991 and 1995. Source: WHOrEURO w12x.
The recent political and economic upheaval in connection with the dissolution of the USSR gave rise to a dramatic increase in the incidence of syphilis in the region: an example Žthe case of Ukraine. is shown in Fig. 2. An equally dramatic rise in the incidence of syphilis has been reported to the WHO inter alia from the Russian Federation, Belarus, and Moldova, with a thirty- to fortyfold increase between the years 1989 and 1995 w12x. In 1995 WHO estimated that by the end of 1994 there were some 18 million adult HIV infections around the world; of these, 11 million cases in Sub-Saharan Africa, 3 million in the Americas and 3 million cases in South and South East Asia w8x. Today, the global total may be approximately 22]23 million, with the highest prevalence in the 15 Sub-Saharan African countries and Thailand. It is projected by the WHO that between 1985 and 2005, the number of cumulative HIV infections in these 16 countries will increase from 5 to almost 30 million, of which approximately 5 million will be pediatric cases w10x. In 1996, the highest prevalence of HIVrAIDS was in WHO’s African Region Ž5.144r100 000 adults., followed by South East Asia Ž694. and the Americas Ž565r100 000.. According to recent estimates w10x, in 1996 there were more than a total of 1.1 million AIDS deaths in the various WHO Regions ŽTable 3.. Since in the same year, the worldwide total of
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Table 3 AIDS deaths in 1996 WHO region Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific Total
Deaths 780 000 150 000 140 000 22 000 11 000 4000 1 107 000
Source: The World Health Report w10x.
all deaths was approximately 52 million, it can be concluded that, as a minimal estimate, more than 2% of all current deaths are AIDS deaths. 2.2.3. Reproducti®e tract malignancies Worldwide mortality from reproductive tract malignancies approaches 1 million people; in 1993, some 358 000 women died from malignant neoplasms of the breast, 235 000 from those of the uterine cervix and 123 000 from ovarian cancer, in addition to 182 000 men who died from prostatic cancer w8x. 2.2.4. Female genital mutilation WHO estimates that there are, at present, some 130 million girls and women, mainly in certain African countries, who have undergone some form of genital mutilation w13x. What is genital mutilation? It is a flagrant violation of fundamental human rights and of the basic principle of gender equity. Recently Ž9 April 1997. the heads of three UN agencies ŽWHO, UNICEF and UNFPA. appealed to the international community and to governments to support efforts aimed at eliminating this harmful and unjustifiable traditional practice. The joint plan of these agencies aims at completely eliminating genital mutilation within two or three generations. 2.2.5. Reproducti®e health among refugees Between 1990 and 1995, the number of refugees increased from 7 to 8 million in Asia, from 1 to 7 million in Europe and from 4 to 11 million in
Africa, but so far insufficient attention is being paid to their specific reproductive health needs. FIGO has recognized the importance of the issue by devoting one of the keynote addresses to it at its XVth World Congress in Copenhagen. 2.2.6. Child mortality In 1970, worldwide under-5-year child mortality was 134r1000 live births and in 1995 it was 82r1000, still exhibiting marked regional differences: it was 8.5r1000 live births in the developed world, 91r1000 in all developing countries and 156r1000 in the least developed countries w9x. However, these figures don’t give justice to the dramatic decrease in child mortality, which took place during the past few decades. Of a worldwide total of 50 million deaths in 1960, 19 million, or 38% were in children; of the 52 million deaths in 1996, only 11 million, or 21% were under the age of 5-years and WHO projects that by the year 2025, of the projected 65 million deaths only some 5.2 million, or 8% will be in children, as shown in Fig. 3. 2.2.7. The importance of reproducti®e health In less than 10 years’ time, reproductive health assumed a dominant importance in global health affairs, indicated inter alia by the fact that seven of the 10 goals set by WHO for the period of 1996]2001 are directly relevant to it w14x. In fact, in less than 10 years’ time, the great majority of the governments of the world recognized that reproductive health is the core of general health and that health is the quintessence of all human development. Reproductive health is not only a fundamental human right for all; it is also a social and economic imperative w7x. Indeed, the general recognition of the need for a holistic approach to reproductive health by governments and the international community represents a major success of one of the great intellectual revolutions of our time. 2.3. The re®olution of gender equity ‘L’extension des privileges des femmes est le ` principe general de tous progres ´ ´ ` sociaux ŽIncreas-
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Fig. 3. Age distribution of deaths and population in the world in 1965, 1995 and 2025. Source: WHO w10x.
ing women’s rights is the general principle of all social progress.’ wrote Charles Fourier in 1808 w15x; since then, the principle of gender equity progressed steadily, albeit rather slowly, until a sudden change occurred and the ICPD in Cairo Ž1994. sharply focused international attention on
the problem. In retrospect, it was to be expected. The contraceptive revolution paved the way for the revolution in reproductive health and the latter for the revolution in gender equity. Although we have witnessed considerable progress during the past few decades, there still is
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a long journey ahead of us, in order to achieve gender equity with respect to the nutrition, health care and education of girls and human rights, income and personal security of women. The present situation could be summarized by stating that, even today, women constitute 70% of the world’s poor and 66% of the illiterate and that women occupy only 10% of all parliamentary seats and 7% of all cabinet positions around the world w16,17x. In 1990, the UN Commission on the Status of Women recommended a 30% threshold of decision-making positions to be held by women. In parliamentary or cabinet representation, only Denmark, Finland, the Netherlands, Norway, Seychelles and Sweden have crossed this threshold and, as far as I know, Sweden is the only country where 50% of all government positions and parliamentary seats are held by women. 3. Healthy ageing In his Defence of Poetry Ž1821., P.B. Shelley talks about ‘The gigantic shadows which futurity casts upon the present’ and, with due respect, I can’t help wondering what he really had in mind? Certainly not what I have in mind, the demographic evolution during a 100-year period, between 1950 and 2050, that is indicated in Table 4. In 1950, the world population was around 2.5 billion people; by the year 2050, it is projected to approach 10 billion w4x. Furthermore, in 1950, worldwide life expectancy at birth for women was less than 48 years and for men around 45 years; today it is around 68 years for women and 64 Table 4 World population Year
Billions
1950 1970 1990 2010 2030 2050
2.5 3.7 5.3 7.0 8.7 9.8
Source: United Nations w4x.
years for men, and the UN projects that by the year 2050, it will exceed 79 years for women and 74 years for men w4x. So, humankind is growing rapidly and aging rapidly and the question is: what is wrong with that? One of the issues is this: who is going to provide for whom in a world inhabited by 10 billion fellow men and women? Meanwhile between 1950 and 2050, the entire dependent population of the world Ži.e. those aged 15 years and less q those aged 65 and more. is expected to diminish slightly from 39.6% to 35.5% of the total population, the elderly population Žaged 65 and above. will increase from 5.1% to 14.7% of the total, whereas the proportion of children Žthose aged 15 and under. will decline from 34.6% to 20.8% w4x. This leads to the next issue: who will provide for the almost 1.5 billion elderly in the year 2050 and thereafter? The ‘classical’ perception, that aging is basically a developed country problem is no longer classical; it is simply erroneous. As indicated in Table 5, the increase in the elderly population will be fastest in South and South-East Asia; whereas between 1990 and 2025, the elderly population of Sweden and of the United Kingdom is expected to increase by 33 and 45%, respectively, the corresponding increase in Indonesia will be 414% and in Thailand 337% w18,19x. Also, as indicated in Table 6, the projected increase in the proportion of the very old, or ‘old-old’ Žpersons aged 80 years and over. will be the fastest in the Asian Region, with a threefold
Table 5 Projected increase in the elderly populationa of selected countries between 1990 and 2025 Country
Percentage increase
Indonesia Thailand India China Bangladesh Australia United Kingdom Sweden
414 337 242 220 219 137 45 33
a
Population aged 65 years and over; source: WHO w18x.
E. Diczfalusy r International Journal of Gynecology & Obstetrics 59 (1997) 195]206 Table 6 Estimated and projected population aged 80 years and over as a percentage of total population Region
Sub-Saharan Africa Latin America Asiaa North America Europea
Year 1990
2010
2025
0.3 0.8 0.6 2.8 3.2
0.3 1.2 1.2 4.0 4.9
0.4 1.8 1.8 4.6 6.4
a
Excluding countries of the former USSR. Source: WHO w18x.
increase between 1990 and 2025, followed by Europe and North America w18,19x. Since the increase in life expectancy for women considerably exceeds that for men w18,20,21x, the gender difference among the elderly can be expected to reach proportions never seen before. A few examples are presented in Table 7. But what about our perception of the ‘gigantic shadows’? They are intimately associated with the fact that the last years of life are accompanied by a marked increase in disability and sickness, with very high demands for expensive health and social services. Hence the soaring elderly population will raise fundamental health-care, social, economic and ethical issues worldwide and may strain to the limit the ability of the existing health, social, economic and even political infrastructures of a large number of countries in their attempts to adapt to the new realities. It may also result in Table 7 Gender difference at the age of 60 years Žselected countries. Country
Women per 100 men
Russian Federation Ukraine People’s Rep. of Korea Germany Republic of Korea USA Japan Thailand China India
224 205 182 159 151 138 127 125 107 102
Source: United Nations w21x.
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an increasingly large proportion of the population Žthe elderly in general and elderly women, in particular. living in absolute poverty. Estimates and projections of the disease burden among the elderly suggest that in addition to the quantitatively most important causes, such as cerebrovascular and cardiovascular diseases, malignant neoplasms and chronic obstructive pulmonary disease w22x, a major increase can be expected in the number of cases of Alzheimer disease and other dementias, certain metabolic diseases, such as diabetes and osteoporotic fractures and in visual and hearing impairment w10x. WHO points out that Alzheimer disease is likely to become one of the leading causes of disability in the elderly worldwide, and that Africa, Asia and Latin America between them could have more than 80 million people with senile dementia in the year 2025. The influence of increasing life expectancy on the number and regional distribution of osteoporotic fractures will also be dramatic and the number of people with diabetes between 2000 and 2025 is expected to double in Africa, the Americas, in the Eastern Mediterranean Region and the Western Pacific and treble in South-East Asia w10x. To cope with these new realities, it will be mandatory to significantly increase national and international support to medical research, including health systems research. It can also be predicted, that the rapid growth of elderly populations will open up a virtually endless frontier of ethical inquiry into our frequently conflicting moral premises, such as an ethically justifiable allocation of scant resources among and between generations and the balance between family and government obligations in providing care for the elderly. Indeed, should there be any limit for the health care of the elderly in such a Brave New World and, if so, who should play the role of a new god by deciding over life and death and who should safeguard the rights of the poor, disabled or demented elderly w19x? Last, but not least, it should also be borne in mind, that a rapidly aging world population is a fundamentally new feature in history, in fact so
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new, that people and their governments have not had sufficient time, vision, willingness and perhaps not even courage to face up to this new reality and to consider the major social, cultural and political readjustments that it will require. Therefore these new realities will be part of a new challenge in a new century. 4. Nine approaches to reality In his immortal poem, Burnt Norton Ž1935., T.S. Eliot says that ‘human kind cannot bear very much reality’. Perhaps this is the reason that we try different approaches to it, and, during a long life, I could observe at least nine such approaches practised, as indicated in Table 8. When these approaches converge } and it happened sometimes in history } progress can be incredibly rapid; if they don’t, then the world becomes a vast temple of discord, with the political approach assuming a controlling role. It is very important to bear in mind that each of these approaches can enormously enrich human existence. However, it is equally important to understand that their impact on society is not equal, and that, as P.C. Snow observed, ‘The scientific revolution is the only method by which most people can gain the primal things Žyears of life, freedom from hunger, survival for children.’. I am also convinced that among the nine approaches indicated in Table 7, only the scientific one is capable of providing an acceptable quality of life for the 10 billion fellow men and women living in the 21st century, among them some 1.5 billion elderly. But why? Is science really omnipotent? Table 8 NINE APPROACHES TO REALITY SCIENTIFIC CULTURAL RELIGIOUS ETHICAL ECONOMICAL ECOLOGICAL SOCIOCRITICAL PHILOSOPHICAL POLITICAL
Table 9 NINE PILLARS OF HUMAN DIGNITY SUFFICIENT FOOD POTATO WATER SHELTER SANITATION HEALTH SERVICES HEALTHY ENVIRONMENT EDUCATION EMPLOYMENT PERSONAL SECURITY
Certainly not. As Albert Einstein said: ‘One thing I have learned in a long life: that all our science, measured against reality, is primitive and childlike } and yet it is the most precious thing we have’. Indeed, all our human knowledge is imperfect and will remain imperfect forever; however, it is indefinitely perfectible. Therefore science does represent our best hope for a brighter future. 5. Nine pillars of human dignity A discussion of the nine revolutions of our time and the nine approaches to reality must necessarily lead to a consideration of the nine pillars of human dignity, since I am convinced that the greatest of all social revolutions of the next century will be a universal search for human dignity. The nine pillars are indicated in Table 9. I am convinced that in the next centuries of the third millennium a world can be created in which every human being has access to sufficient food, potable water, shelter, sanitation, health services, a healthy environment, education, employment and personal security. Do you think that this is utterly naive? ‘A hope beyond the shadow of a dream’? to use the words of John Keats from his Endymion. Certainly not It can happen, if we let it happen. Never before has humankind had so many resources, so much knowledge and such powerful technologies at its disposal. Yes, but what about human nature? Can it really be changed? I think so. All evolutionary biology suggests that human nature is not destiny. It can change and can be changed by time and circumstances. All this can happen, if we let it happen.
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6. FIGO and our common future In 1961, Bertrand Russell remarked that ‘In a biological sense, Man, the latest of species, is still an infant. No limit can be set to what he may achieve in the future’. Similarly, no limit can be set to what FIGO may achieve in the future. Indeed, FIGO can look forward with a robust confidence to a future that is infinitely longer than its past. It was the broad vision of Hubert de Watteville ŽFig. 4. which led to the establishment of FIGO in 1954. Would he be here today, he could say with at least as much, if not more, justification what Horace said: ‘Exegi monumentum aere perennius’ Ž Odes III, xxx, 1.; ‘My work is done, the memorial more enduring than brass’. Why? Because when an idea meets the necessity of an epoch, it ceases to belong to those who invented it and becomes much stronger than those who are in charge of it, to quote Jean Monnet Ž1978.. FIGO doesn’t any longer belong to its member societies; it belongs to humankind as one of our important instruments for improving the human condition. There is an old Chinese proverb, saying that ‘A journey of a thousand miles must begin with a single step’; perhaps the ‘Save the Mothers’ initiative taken at this Congress may constitute such a step. Now FIGO is facing a long journey of 1000 miles and perhaps 1000 years to reach our dream and ultimate goal: the world of human dignity. And since in this existence, travelling is at least as important as arriving, I wish FIGO a very happy and satisfying journey into the third millennium, full of achievements along the road to diminish suffering and improve the status of the women of the world. What should FIGO take along for this long journey, in addition to the breadth of vision of Hubert de Watteville? Two things, for which FIGO is respected and admired all over the world: scientia et caritas; science and charity. Perhaps also something more; take along the infinite wisdom of hope and the words of the great Hungarian poet, Imre Madach ´ from the 19th century: ‘Mondottam ember: kuzdj’ bızzal’; ¨ ´es bızva ´ ´ ´ Oh Man, strive on, strive on, have faith; and trust.
Fig. 4. Professor Hubert de Watteville, Geneva, founder and first President of FIGO.
References w1x The World Commission on Environment and Development. Our common future. Oxford: Oxford University Press, 1987. w2x World Health Organization. Maternal and child health and family planning: the health situation of women, children and families and programme experiences. An overview based upon materials and analysis prepared for the 7th Expert Committee on Maternal and Child Health. FHErMCHr94.1. Geneva: World Health Organization, 1994. w3x United Nations. Levels and trends of contraceptive use, as assessed in 1988. New York: United Nations, 1989. w4x United Nations. World population prospects. The 1994 revision. New York: United Nations, 1995. w5x Shah IH. The advance of the contraceptive revolution. World Health Stat Q 1994;47:9]15. w6x World Health Organization. Health, population and development; WHO position paper for the international conference on population and development, Cairo, 1994. WHOrFHEr94. Geneva: World Health Organization, 1994.
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w7x United Nations. Report of the international conference on population and development, Cairo, 1994. ArCONF:171r13. New York: United Nations, 1994. w8x World Health Organization. The world health report 1995. Bridging the gaps. Geneva: World Health Organization, 1995. w9x World Health Organization. The world health report 1996. Fighting disease fostering development. Geneva: World Health Organization, 1996. w10x World Health Organization. The world health report 1997. Conquering suffering. Enriching humanity. Geneva: World Health Organization, 1997. w11x VanLook PFA. Reproductive health: the fifth freedom revisited. Paper presented at the XVth Asian and Oceanic Congress of Obstetrics and Gynecology, Bali, October, 1995. In: Diczfalusy E, editor. The contraceptive revolution } an era of scientific and social development. Casterton Hall, Carnforth: The Parthenon Publishing Group, 1997:218. w12x Gromyko A. The challenge of rising trends in the incidence of sexually transmitted diseases in Eastern Europe. Acta Obstet Gynecol Scand 1997;Suppl. 76:4ŽSE61.3.. w13x World Health Organization. Female genital mutilation. Report of a WHO Technical Working Group, Geneva, 17]19 July 1995. WHOrFRHrWHDr96.10. Geneva: World Health Organization, 1996.
w14x World Health Organization. Ninth general programme of work covering the period of 1996]2001. Health for all series, No. 11. Geneva: World Health Organization, 1994. w15x Fourier FMC. Theorie des quatre mouvements et des ´ destinees Lyon: A. Leipzig, 1808. ´ generales. ´ ´ w16x United Nations Population Fund ŽUNFPA.. The state of world population 1995. New York: UNFPA, 1995:43. w17x United Nations Children’s Fund ŽUNICEF.. The progress of nations. New York: UNICEF, 1997. w18x World Health Organization. Epidemiology and prevention of cardiovascular diseases in elderly people. WHO Tech. Rep. Ser. No. 853. Geneva: World Health Organization, 1995. w19x Diczfalusy E, Benagiano G. Women and the third and fourth age. Int J Gynecol Obstet 1997;58:177]188. w20x United Nations. World economic and social survey 1995. Current trends and policies in the world economy. New York: United Nations, 1995. w21x United Nations. The World’s Women 1995. Trends and statistics. STrESArSTATrSER.Kr12. New York: United Nations, 1995. w22x The World Bank. World development report 1993. Investing in health. Oxford: Oxford University Press, 1993.
Special article
In search of human dignity: gender equity, reproductive health and healthy aging Egon Diczfalusy Karolinska Institutet, Stockholm, Sweden Received 8 September 1997; accepted 26 September 1997
Abstract This paper analyzes the nine pillars of human dignity Žsufficient food, potable water, shelter, sanitation, health services, healthy environment, education, employment and personal security., which humankind tries to establish by following nine approaches to reality Žscientific, cultural, religious, ethical, economical, ecological, socio-critical, philosophical and political. in a world drastically changed by nine re®olutions Ždemographic, scientific, technological, communication, global identity, environmental, contraceptive, reproductive health and gender equity.. The author’s generation participated in these revolutions and contributed to the global intellectual process by which gender equity and reproductive health assumed a central role in world affairs. A rapidly aging world population constitutes another major challenge. Its likely impact on the very fundaments of our future social, economical, health and even political infrastructures is } as yet } incompletely comprehended by the international community. The International Federation of Gynecology and Obstetrics ŽFIGO. has and will continue to have an indispensable role in assisting humankind to reach its ultimate goal : human dignity. Q 1997 International Journal of Gynecology and Obstetrics
The following is the text of the Hubert de Watte®ille Memorial Lecture, presented by Professor Egon Diczfalusy in honor of Professor Hubert de Watte®ille, the first president of The International Federation of Gynecology and Obstetrics (FIGO), at the XV FIGO World Congress of Gynecology and Obstetrics in Copenhagen, Denmark in August 1997. Professor de Watte®ille was an extraordinary and ®isionary indi®idual who had an enormous impact on the specialty of obstetrics and gynecology. Under
the personal guidance of Professor de Watte®ille, the International Federation of Gynecology and Obstetrics (FIGO) was founded in 1954 in Gene®a, Switzerland, with Professor de Watte®ille as the first president. Four years later, at the Second World Congress held in Montreal, Canada, Professor de Watte®ille was named Secretary General of FIGO, with the Secretariat being established in Gene®a, where it remained for approximately 25 years. Professor de Watte®ille’s dedication and enthusiasm,
0020-7292r97r$17.00 Q 1997 International Federation of Gynecology and Obstetrics PII S0020-7292Ž97.00230-0
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coupled with his limitless energy and international contacts, lent great strength to the Federation in those de®eloping years. His legacy carries on in the FIGO world congresses and in the e®er-increasing role of FIGO in international obstetrics and gynecology. It is also noteworthy that Professor de Watte®ille was instrumental in the formation of the International Federation of Fertility Societies (IFFS) and ser®ed as president of that multinational group. Following Professor de Watte®ille’s death in 1984, the executi®e boards of FIGO and IFFS collaborated in establishing the Hubert de Watte®ille Memorial Lecture series. At the triennial world congresses of each organization, a de Watte®ille Memorial Lecture is presented. The lecturer is selected by a committee composed of past presidents from both organizations.
1. The human condition: darkness and light
This is the last FIGO Congress of the century and even of the millennium. To deliver the Hubert de Watteville Memorial Lecture on an occasion like this, is not only a great honor, distinction and particular privilege; it is also a major responsibility. Why? Because we are living in difficult times. Well, are not all times difficult times? How did Waldo Emerson say in 1864? ‘These times of ours are serious and full of calamity, but all times are essentially alike’. So, what is the difference? The difference is the rate of change. ‘The rate of change is outstripping the ability of scientific disciplines and our current capabilities to assess and advise’, stated the World Commission on Environment and Development in 1987 w1x. Indeed, the changes around us are accelerating, but our perception of these changes and of their consequences is lagging more and more behind... In times like this, it becomes of crucial importance to have a vision of the future. However, I am convinced, that only those with some knowledge of the past can have a vision of the future. ‘Es bueno vivir mucho para ver mucho Žit is good to live long in order to see much.’, says
Sancho Panza in Don Quijote Ž1620., and I have witnessed most of the history of the 20th century. When I was born, the global population was less than 2 billion people; next year it will exceed 6 billion. Hence, in my lifetime, I have seen the birth of another two worlds, equal in numbers, needs, aspirations, hopes and dreams. Indeed, I have seen much. Perhaps even too much... Schopenhauer remarks in his Parerga und Paralipomena Ž1851., that ‘the man who sees two or three generations is like someone who sits in a conjurer’s booth at a fair, and sees the tricks two or three times; they are meant to be seen only once’. I have seen the tricks of the political ‘magicians’ of three generations. I have seen their flirtation with the apocalypse in the shadow of the hydrogen bomb and I have frequently seen the two powerful determinants of human destiny: the arrogance of power and the arrogance of ignorance. Then Sancho Panza continues: ‘El que larga vida vive mucho mal ha da pasar Žthose who live long also pass through much evil.’ and I have seen a fair amount of it, witnessing the history of a century in which some 200 million human beings were killed } frequently in a deliberate and systematic fashion } by other human beings, on orders of the ‘magicians’. I have seen plenty of the dark aspects of what we call ‘human nature’, be it violence, aggression, barbarity, terror and cruelty, hypocrisy, moral and intellectual corruption and naked cynicism and I have learned, like Publilius Syrus did 2000 years earlier, that ‘cruelty isn’t softened by tears; it feeds on them’. However, as Alexander Pope said Ž1735., ‘there must be shadows, if there should be light’ and I have also seen an incredible amount of light. In my lifetime, I have seen more progress in science and technology, than all scientists of all preceding periods together, since the dawn of history. The reason for this is simple mathematics; as it was observed by Friedrich Engels ‘science progresses in proportion to the mass of knowledge that is left to it by preceding generations, that is under the most ordinary circumstances in geometrical proportion’. I have also seen nine major revolutions, as indicated below.
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2. Nine revolutions I have witnessed Žand frequently participated in. nine powerful revolutions, that have profoundly changed our world and our perception of it. According to the Oxford English Dictionary, the word revolution has multiple meanings; it may mean movement round an axis, the movement of certain celestial bodies, a complete overthrow of a government, or a great change in affairs or things, and I use the word in this latter context. The nine revolutions of my time Žas I perceive them today. were those shown in Table 1. Only a few of them require any comments. The revolution in communication is, of course, part of the technological revolution. I list it separately, however, since it assumed a commanding role in human affairs in a world where the medium became more important than the message. The revolution of global identity is perhaps the most characteristic change of the 20th century. It is true that our world has never been more integrated and more fragmented at the same time; however, this development Žlike all developments. must be viewed in a broad historical perspective. Indeed, the 20th century was the first time in history when humankind dared to establish the United Nations with its numerous Specialized Agencies, like the World Health Organization and with hundreds of international professional associations, some of them, like FIGO, immediately making a major global impact. Also, the 20th century was the first time when humankind felt capable of providing large-scale help and Table 1 NINE REVOLUTIONS DEMOGRAPHIC SCIENTIFIC TECHNOLOGICAL COMMUNICATION GLOBAL IDENTITY ENVIRONMENTAL CONTRACEPTIVE REPRODUCTIVE HEALTH GENDER EQUITY
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assistance to those stricken by famine, or natural catastrophes in any corner of the world, and we are only at the very beginning of this irreversible process. The general acceptance of our global identity led then to the environmental revolution, the recognition of the fact that our environment is perhaps the most precious thing we have in common. When I was young, the concept of the environment simply didn’t exist; there was only ‘Mother Nature’, as we perceived it, with the self-evident role to provide in an unlimited manner all our material needs, including the disposal of any amount of waste generated by the human race on a rapidly increasing scale. The last three revolutions shown in Table 1 were intellectual ]technical in nature, sequential and truly global in character. They will have a major impact also on the history of the 21st century. These three revolutions will be discussed briefly below. 2.1. The contracepti®e re®olution The credit should undoubtedly go to the Government of India for establishing in 1952, for the first time in history, a national family planning program. This was done boldly and with courage at a time when no modern contraceptives Žoral pills, intrauterine devices. were as yet available and the international atmosphere was explicitly hostile to family planning. Of course, one may wonder, whether there ever existed an ‘international atmosphere’ that was not hostile to any new idea. At any rate, the example of India was rapidly followed by other countries and today some 150 governments support, directly or indirectly, family planning programs. The introduction of oral contraceptives and intrauterine devices in the late 1950s and early 1960s resulted in a quantum leap in contraceptive prevalence, as shown in Fig. 1 w2x. Whereas in 1960, the number of contraceptive users in the developing world was around 30 million, by 1990 their number exceeded 380 million w3x. Around 1990, worldwide contraceptive prevalence was 57%; it was highest Ž79%. in Eastern Asia and lowest Ž18%. in Africa w4x.
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Fig. 1. Increase of contraceptive prevalence in the world between 1960 and 2000. Source: WHO w2x.
Viewed globally, by the year 2000, tubectomy will remain the most widely used method Ž207 million users., followed by intrauterine devices Ž125 million. and oral, injectable and implantable steroidal contraceptives Žalmost 100 million., vasectomy Ž47 million., condom use Ž35 million. and a variety of traditional methods, with an estimated 57 million users w5x. Whether today, with more than 0.5 billion contraceptive users the contraceptive revolution still should be considered a revolution, or just a generally accepted daily routine, that improves the quality of life of 1 billion human beings, is a matter of opinion. It can be taken for granted, however, that contraception has come to stay.
health appears from the global estimates of reproductive ill-health. According to recent estimates by WHO, some 120 million people still have unmet family planning needs; some 130 million women have been subjected to genital mutilation; there are some 60]80 million infertile couples; at least 20 million adults are living with HIVrAIDS and 2 million women with invasive cervical cancer w8]10x. Annually there are some 330 million new cases of sexually transmissible diseases, 20 million unsafe abortions and the same number of cases with severe maternal morbidity. The under-5-year mortality is around 12 million and there are some 7 million perinatal deaths. Each year some 25 million infants are born with low birth-weight Ž17% of the total.. Annually, there are almost 3 million new cases of HIV infection, 2 million cases of female genital mutilation, 0.5 million new cases of cervical cancer and some 600 000 cases of maternal mortality, the majority of which could be prevented. How did Andre ´ Malraux say? ‘A human life is worth nothing; but nothing is worth a human life’. Are the governments of this world really doing their utmost to prevent maternal deaths? And the international community? It is heartening to see that FIGO is not willing to accept this state of affairs and is launching at its XVth Congress the ‘Save the Mothers’ initiative. Because of limitations of space, only some aspects of reproductive health can briefly be considered below.
2.2. The re®olution in reproducti®e health Contraception is an extremely important dimension of reproductive health, but only one of several dimensions. The credit should go to the World Health Organization ŽWHO. for initiating the revolution in reproductive health with a position paper w6x presented to the United Nations International Conference on Population and Development ŽICPD; Cairo September 1994. and also to ICPD for adopting the WHO document as the cornerstone of the United Nations ŽUN. action program in this field w7x. The overwhelming importance of reproductive
2.2.1. Maternal mortality and abortion There is indeed a tremendous scope to reduce maternal mortality and morbidity. In 1990, maternal mortality was as low as seven per 100 000 live births in Spain, or Hongkong and as high as 1400r100 000 live births in Ethiopia, or 1600r100 000 live births in Somalia. What do such figures mean? They indicate that the lifetime risk of a woman of dying from pregnancy-related causes is 1:7 in Somalia and 1:9200 in Hongkong w9x. Who is willing to accept such a situation when humankind enters the 21st century? Certainly not FIGO
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More than 11% of the 585 000 maternal deaths annually are attributable to unsafe abortions, most of them in Asia and Africa w2x. Abortion laws are markedly different around the world: whereas the laws of 173 countries accept abortion to save the life of a woman, only 119 accept it to preserve her physical health and only 95 to preserve her mental health. Rape or incest as an indication is accepted by 81, fetal impairment by 78 and socioeconomic reasons by 56 countries. Abortion is available upon request in 41 countries w16x. It would appear that, in general, the abortion laws in developing countries are more restrictive than in developed countries, as indicated by the data of Table 2 w11x. The international debate over abortion issues has always been emotional, sometimes even passionate, and, more often than not, it generated more heat than light. In my own view, the position taken by President Clinton carries a great deal of weight: ‘We believe abortion should be safe, legal and rare’. 2.2.2. Sexually transmissible diseases (STDs), including HIV r AIDS WHO estimates that among the more than 330 million new cases of STDs that occurred in 1995, there were some 89 million chlamydial, 62 million gonococcal and 12 million syphilitic infections, in addition to some 170 million cases of trichomoniasis. Chlamydia, gonorrhea and syphilis are frequently associated with a high prevalence of infertility and might increase the risk of sexual transmission of HIV infection w9x. Table 2 Grounds on which abortion is permitted in developed and developing countries Indication
To save the life of a woman To preserve her physical health To preserve her mental health Rape or incest Fetal impairment Socioeconomic reasons Available upon request Source: Van Look w11x.
Percentage of countries Developed
Developing
94.4 88.9 88.9 86.1 83.3 80.6 55.6
86.2 46.0 32.2 23.0 21.8 8.0 4.6
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Fig. 2. Increase in the incidence of syphilis in the Ukraine between 1991 and 1995. Source: WHOrEURO w12x.
The recent political and economic upheaval in connection with the dissolution of the USSR gave rise to a dramatic increase in the incidence of syphilis in the region: an example Žthe case of Ukraine. is shown in Fig. 2. An equally dramatic rise in the incidence of syphilis has been reported to the WHO inter alia from the Russian Federation, Belarus, and Moldova, with a thirty- to fortyfold increase between the years 1989 and 1995 w12x. In 1995 WHO estimated that by the end of 1994 there were some 18 million adult HIV infections around the world; of these, 11 million cases in Sub-Saharan Africa, 3 million in the Americas and 3 million cases in South and South East Asia w8x. Today, the global total may be approximately 22]23 million, with the highest prevalence in the 15 Sub-Saharan African countries and Thailand. It is projected by the WHO that between 1985 and 2005, the number of cumulative HIV infections in these 16 countries will increase from 5 to almost 30 million, of which approximately 5 million will be pediatric cases w10x. In 1996, the highest prevalence of HIVrAIDS was in WHO’s African Region Ž5.144r100 000 adults., followed by South East Asia Ž694. and the Americas Ž565r100 000.. According to recent estimates w10x, in 1996 there were more than a total of 1.1 million AIDS deaths in the various WHO Regions ŽTable 3.. Since in the same year, the worldwide total of
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Table 3 AIDS deaths in 1996 WHO region Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific Total
Deaths 780 000 150 000 140 000 22 000 11 000 4000 1 107 000
Source: The World Health Report w10x.
all deaths was approximately 52 million, it can be concluded that, as a minimal estimate, more than 2% of all current deaths are AIDS deaths. 2.2.3. Reproducti®e tract malignancies Worldwide mortality from reproductive tract malignancies approaches 1 million people; in 1993, some 358 000 women died from malignant neoplasms of the breast, 235 000 from those of the uterine cervix and 123 000 from ovarian cancer, in addition to 182 000 men who died from prostatic cancer w8x. 2.2.4. Female genital mutilation WHO estimates that there are, at present, some 130 million girls and women, mainly in certain African countries, who have undergone some form of genital mutilation w13x. What is genital mutilation? It is a flagrant violation of fundamental human rights and of the basic principle of gender equity. Recently Ž9 April 1997. the heads of three UN agencies ŽWHO, UNICEF and UNFPA. appealed to the international community and to governments to support efforts aimed at eliminating this harmful and unjustifiable traditional practice. The joint plan of these agencies aims at completely eliminating genital mutilation within two or three generations. 2.2.5. Reproducti®e health among refugees Between 1990 and 1995, the number of refugees increased from 7 to 8 million in Asia, from 1 to 7 million in Europe and from 4 to 11 million in
Africa, but so far insufficient attention is being paid to their specific reproductive health needs. FIGO has recognized the importance of the issue by devoting one of the keynote addresses to it at its XVth World Congress in Copenhagen. 2.2.6. Child mortality In 1970, worldwide under-5-year child mortality was 134r1000 live births and in 1995 it was 82r1000, still exhibiting marked regional differences: it was 8.5r1000 live births in the developed world, 91r1000 in all developing countries and 156r1000 in the least developed countries w9x. However, these figures don’t give justice to the dramatic decrease in child mortality, which took place during the past few decades. Of a worldwide total of 50 million deaths in 1960, 19 million, or 38% were in children; of the 52 million deaths in 1996, only 11 million, or 21% were under the age of 5-years and WHO projects that by the year 2025, of the projected 65 million deaths only some 5.2 million, or 8% will be in children, as shown in Fig. 3. 2.2.7. The importance of reproducti®e health In less than 10 years’ time, reproductive health assumed a dominant importance in global health affairs, indicated inter alia by the fact that seven of the 10 goals set by WHO for the period of 1996]2001 are directly relevant to it w14x. In fact, in less than 10 years’ time, the great majority of the governments of the world recognized that reproductive health is the core of general health and that health is the quintessence of all human development. Reproductive health is not only a fundamental human right for all; it is also a social and economic imperative w7x. Indeed, the general recognition of the need for a holistic approach to reproductive health by governments and the international community represents a major success of one of the great intellectual revolutions of our time. 2.3. The re®olution of gender equity ‘L’extension des privileges des femmes est le ` principe general de tous progres ´ ´ ` sociaux ŽIncreas-
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Fig. 3. Age distribution of deaths and population in the world in 1965, 1995 and 2025. Source: WHO w10x.
ing women’s rights is the general principle of all social progress.’ wrote Charles Fourier in 1808 w15x; since then, the principle of gender equity progressed steadily, albeit rather slowly, until a sudden change occurred and the ICPD in Cairo Ž1994. sharply focused international attention on
the problem. In retrospect, it was to be expected. The contraceptive revolution paved the way for the revolution in reproductive health and the latter for the revolution in gender equity. Although we have witnessed considerable progress during the past few decades, there still is
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a long journey ahead of us, in order to achieve gender equity with respect to the nutrition, health care and education of girls and human rights, income and personal security of women. The present situation could be summarized by stating that, even today, women constitute 70% of the world’s poor and 66% of the illiterate and that women occupy only 10% of all parliamentary seats and 7% of all cabinet positions around the world w16,17x. In 1990, the UN Commission on the Status of Women recommended a 30% threshold of decision-making positions to be held by women. In parliamentary or cabinet representation, only Denmark, Finland, the Netherlands, Norway, Seychelles and Sweden have crossed this threshold and, as far as I know, Sweden is the only country where 50% of all government positions and parliamentary seats are held by women. 3. Healthy ageing In his Defence of Poetry Ž1821., P.B. Shelley talks about ‘The gigantic shadows which futurity casts upon the present’ and, with due respect, I can’t help wondering what he really had in mind? Certainly not what I have in mind, the demographic evolution during a 100-year period, between 1950 and 2050, that is indicated in Table 4. In 1950, the world population was around 2.5 billion people; by the year 2050, it is projected to approach 10 billion w4x. Furthermore, in 1950, worldwide life expectancy at birth for women was less than 48 years and for men around 45 years; today it is around 68 years for women and 64 Table 4 World population Year
Billions
1950 1970 1990 2010 2030 2050
2.5 3.7 5.3 7.0 8.7 9.8
Source: United Nations w4x.
years for men, and the UN projects that by the year 2050, it will exceed 79 years for women and 74 years for men w4x. So, humankind is growing rapidly and aging rapidly and the question is: what is wrong with that? One of the issues is this: who is going to provide for whom in a world inhabited by 10 billion fellow men and women? Meanwhile between 1950 and 2050, the entire dependent population of the world Ži.e. those aged 15 years and less q those aged 65 and more. is expected to diminish slightly from 39.6% to 35.5% of the total population, the elderly population Žaged 65 and above. will increase from 5.1% to 14.7% of the total, whereas the proportion of children Žthose aged 15 and under. will decline from 34.6% to 20.8% w4x. This leads to the next issue: who will provide for the almost 1.5 billion elderly in the year 2050 and thereafter? The ‘classical’ perception, that aging is basically a developed country problem is no longer classical; it is simply erroneous. As indicated in Table 5, the increase in the elderly population will be fastest in South and South-East Asia; whereas between 1990 and 2025, the elderly population of Sweden and of the United Kingdom is expected to increase by 33 and 45%, respectively, the corresponding increase in Indonesia will be 414% and in Thailand 337% w18,19x. Also, as indicated in Table 6, the projected increase in the proportion of the very old, or ‘old-old’ Žpersons aged 80 years and over. will be the fastest in the Asian Region, with a threefold
Table 5 Projected increase in the elderly populationa of selected countries between 1990 and 2025 Country
Percentage increase
Indonesia Thailand India China Bangladesh Australia United Kingdom Sweden
414 337 242 220 219 137 45 33
a
Population aged 65 years and over; source: WHO w18x.
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Sub-Saharan Africa Latin America Asiaa North America Europea
Year 1990
2010
2025
0.3 0.8 0.6 2.8 3.2
0.3 1.2 1.2 4.0 4.9
0.4 1.8 1.8 4.6 6.4
a
Excluding countries of the former USSR. Source: WHO w18x.
increase between 1990 and 2025, followed by Europe and North America w18,19x. Since the increase in life expectancy for women considerably exceeds that for men w18,20,21x, the gender difference among the elderly can be expected to reach proportions never seen before. A few examples are presented in Table 7. But what about our perception of the ‘gigantic shadows’? They are intimately associated with the fact that the last years of life are accompanied by a marked increase in disability and sickness, with very high demands for expensive health and social services. Hence the soaring elderly population will raise fundamental health-care, social, economic and ethical issues worldwide and may strain to the limit the ability of the existing health, social, economic and even political infrastructures of a large number of countries in their attempts to adapt to the new realities. It may also result in Table 7 Gender difference at the age of 60 years Žselected countries. Country
Women per 100 men
Russian Federation Ukraine People’s Rep. of Korea Germany Republic of Korea USA Japan Thailand China India
224 205 182 159 151 138 127 125 107 102
Source: United Nations w21x.
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an increasingly large proportion of the population Žthe elderly in general and elderly women, in particular. living in absolute poverty. Estimates and projections of the disease burden among the elderly suggest that in addition to the quantitatively most important causes, such as cerebrovascular and cardiovascular diseases, malignant neoplasms and chronic obstructive pulmonary disease w22x, a major increase can be expected in the number of cases of Alzheimer disease and other dementias, certain metabolic diseases, such as diabetes and osteoporotic fractures and in visual and hearing impairment w10x. WHO points out that Alzheimer disease is likely to become one of the leading causes of disability in the elderly worldwide, and that Africa, Asia and Latin America between them could have more than 80 million people with senile dementia in the year 2025. The influence of increasing life expectancy on the number and regional distribution of osteoporotic fractures will also be dramatic and the number of people with diabetes between 2000 and 2025 is expected to double in Africa, the Americas, in the Eastern Mediterranean Region and the Western Pacific and treble in South-East Asia w10x. To cope with these new realities, it will be mandatory to significantly increase national and international support to medical research, including health systems research. It can also be predicted, that the rapid growth of elderly populations will open up a virtually endless frontier of ethical inquiry into our frequently conflicting moral premises, such as an ethically justifiable allocation of scant resources among and between generations and the balance between family and government obligations in providing care for the elderly. Indeed, should there be any limit for the health care of the elderly in such a Brave New World and, if so, who should play the role of a new god by deciding over life and death and who should safeguard the rights of the poor, disabled or demented elderly w19x? Last, but not least, it should also be borne in mind, that a rapidly aging world population is a fundamentally new feature in history, in fact so
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new, that people and their governments have not had sufficient time, vision, willingness and perhaps not even courage to face up to this new reality and to consider the major social, cultural and political readjustments that it will require. Therefore these new realities will be part of a new challenge in a new century. 4. Nine approaches to reality In his immortal poem, Burnt Norton Ž1935., T.S. Eliot says that ‘human kind cannot bear very much reality’. Perhaps this is the reason that we try different approaches to it, and, during a long life, I could observe at least nine such approaches practised, as indicated in Table 8. When these approaches converge } and it happened sometimes in history } progress can be incredibly rapid; if they don’t, then the world becomes a vast temple of discord, with the political approach assuming a controlling role. It is very important to bear in mind that each of these approaches can enormously enrich human existence. However, it is equally important to understand that their impact on society is not equal, and that, as P.C. Snow observed, ‘The scientific revolution is the only method by which most people can gain the primal things Žyears of life, freedom from hunger, survival for children.’. I am also convinced that among the nine approaches indicated in Table 7, only the scientific one is capable of providing an acceptable quality of life for the 10 billion fellow men and women living in the 21st century, among them some 1.5 billion elderly. But why? Is science really omnipotent? Table 8 NINE APPROACHES TO REALITY SCIENTIFIC CULTURAL RELIGIOUS ETHICAL ECONOMICAL ECOLOGICAL SOCIOCRITICAL PHILOSOPHICAL POLITICAL
Table 9 NINE PILLARS OF HUMAN DIGNITY SUFFICIENT FOOD POTATO WATER SHELTER SANITATION HEALTH SERVICES HEALTHY ENVIRONMENT EDUCATION EMPLOYMENT PERSONAL SECURITY
Certainly not. As Albert Einstein said: ‘One thing I have learned in a long life: that all our science, measured against reality, is primitive and childlike } and yet it is the most precious thing we have’. Indeed, all our human knowledge is imperfect and will remain imperfect forever; however, it is indefinitely perfectible. Therefore science does represent our best hope for a brighter future. 5. Nine pillars of human dignity A discussion of the nine revolutions of our time and the nine approaches to reality must necessarily lead to a consideration of the nine pillars of human dignity, since I am convinced that the greatest of all social revolutions of the next century will be a universal search for human dignity. The nine pillars are indicated in Table 9. I am convinced that in the next centuries of the third millennium a world can be created in which every human being has access to sufficient food, potable water, shelter, sanitation, health services, a healthy environment, education, employment and personal security. Do you think that this is utterly naive? ‘A hope beyond the shadow of a dream’? to use the words of John Keats from his Endymion. Certainly not It can happen, if we let it happen. Never before has humankind had so many resources, so much knowledge and such powerful technologies at its disposal. Yes, but what about human nature? Can it really be changed? I think so. All evolutionary biology suggests that human nature is not destiny. It can change and can be changed by time and circumstances. All this can happen, if we let it happen.
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6. FIGO and our common future In 1961, Bertrand Russell remarked that ‘In a biological sense, Man, the latest of species, is still an infant. No limit can be set to what he may achieve in the future’. Similarly, no limit can be set to what FIGO may achieve in the future. Indeed, FIGO can look forward with a robust confidence to a future that is infinitely longer than its past. It was the broad vision of Hubert de Watteville ŽFig. 4. which led to the establishment of FIGO in 1954. Would he be here today, he could say with at least as much, if not more, justification what Horace said: ‘Exegi monumentum aere perennius’ Ž Odes III, xxx, 1.; ‘My work is done, the memorial more enduring than brass’. Why? Because when an idea meets the necessity of an epoch, it ceases to belong to those who invented it and becomes much stronger than those who are in charge of it, to quote Jean Monnet Ž1978.. FIGO doesn’t any longer belong to its member societies; it belongs to humankind as one of our important instruments for improving the human condition. There is an old Chinese proverb, saying that ‘A journey of a thousand miles must begin with a single step’; perhaps the ‘Save the Mothers’ initiative taken at this Congress may constitute such a step. Now FIGO is facing a long journey of 1000 miles and perhaps 1000 years to reach our dream and ultimate goal: the world of human dignity. And since in this existence, travelling is at least as important as arriving, I wish FIGO a very happy and satisfying journey into the third millennium, full of achievements along the road to diminish suffering and improve the status of the women of the world. What should FIGO take along for this long journey, in addition to the breadth of vision of Hubert de Watteville? Two things, for which FIGO is respected and admired all over the world: scientia et caritas; science and charity. Perhaps also something more; take along the infinite wisdom of hope and the words of the great Hungarian poet, Imre Madach ´ from the 19th century: ‘Mondottam ember: kuzdj’ bızzal’; ¨ ´es bızva ´ ´ ´ Oh Man, strive on, strive on, have faith; and trust.
Fig. 4. Professor Hubert de Watteville, Geneva, founder and first President of FIGO.
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