The feminist women's health movement in Brazil has attained considerable breadth and influence in Brazilian society. This article gives an historical vision of the road travelled and of its achievements. An important year was 1984, when feminist health groups were invited by state services to evaluate and train the officials in charge of the Integrated Women's Health Care Programme (PAISM). Leaflets produced by feminist groups have been reproduced by government bodies.

This experience of Brazilian women is interesting and we feel that we should reflect on it. The year 1983 was one of debate and discussion around women's health in Brazil. The federal government, through the Health Ministry, announced its Integrated Women's Health Care Programme (PAISM), at the same time as the government of the state of Sao Paulo, through the Health Secretariat, announced its Women's Health Programme. Feminists also intensified their meetings and gatherings, culminating in the First National Meeting on Women's Health (November 1984).

We reproduce here extracts from documents taken from meetings held between 1980 and 1983. These give us an historical vision of the women's health movement in Brazil and show the evolution of feminist thought with respect to government policies. This historical account begins with the 1980 dossier by the Family Planning Studies Committee of Sao Paulo's feminist groups, formed at the Valhinos meeting (June 1980, SP). The aim of the dossier was to provide feminist groups, independent feminists and other interested groups and individuals with some background for the discussion. The following is an extract of the dossier:

THE 1980 DOSSIER

In the 1950s, the center of interest for birth control policies was Asia. Later, in the early 1960s, interest spread to Africa and Latin America. One of the first institutions to begin family planning activities was the Civil Society for Family Welfare (BEMFAM), created in 1965 and financed by the International Planned Parenthood Federation. It set itself the task of "promoting community integration programmes with the aim of reducing the number of children in the low-income sectors of society" (in Folha de Sao Paulo, 24 June 1980).

Other institutions besides BEMFAM, such as the Population Council, had been working since the early 1960s in collaboration with university programmes to promote research in the field of reproduction and human biology and, at the same time to carry out programmes on a very small scale in family planning. In this way, an adequate climate was created in the people for experimentation with a series of contraceptives.

According to an analysis by Rocha Rodriguez, "the position of the Brazilian government remains ambiguous. The country takes up a markedly natalistic attitude in international conferences. This is reflected in legislation establishing a family salary and maternity assistance, and prohibiting publicity for contraceptive methods, sterilization and abortion. On the other hand, BEMFAM operates freely in Brazil, widening its activities and even coming to agreements with universities, towns and state governments."

In 1977 the position of the Brazilian government became clearer with the implementation of a High Risk Pregnancy Programme. The justification was the prevention of the risks of pregnancy among the poor population through the use of orally administered contraceptives, among others. This way, the maternal and infant death rate could be kept down - an absolutely aberrant reasoning: if a woman suffers from pregnancy risks through undernourishment, diabetes, etc., the risk of using the pill is even greater. Evidently there was no interest in improving the health of women, but in reducing the poor population.

The year 1980 is an important date in the history of birth control programmes in Brazil. For the first time, the question of family planning appeared explicitly in a government project, the PREV-SAUDE. This government plan was criticized for its authoritarian character: a programme drawn up by a ministry, without taking into consideration the opinions of the social sectors interested, principally women.

WOMEN'S DEMANDS

In the first half of 1983, several meetings were held, mainly in Sao Paulo and Rio de Janeiro, where women put forth their demands on health. These can be summarized as follows:

1. Integrated attention to the health needs of women in all stages of life by creating within each health center or unit, a specific sector including gynaecological care and cancer prevention.
2. The formation of male and female discussion groups in all health units on sexuality and reproduction.
3. The implementation, after an exhaustive discussion with institutions, feminist groups and organizations and other people's organizations, of a family planning programme giving men and women the knowledge and access to all methods of contraception, so that they may have a free and conscious right to the control of their reproduction. Manipulative state policies, natalistic or antinatalistic, should not be tolerated.
4. Promotion of research-on safe and harmless contraceptive methods for both men and women, so that contraception may become a responsibility shared by both sexes. The manufacture of all accepted methods, such as the diaphragm and the IUD.
5. Free abortion for women who wish it after an unwanted pregnancy. Guidance for women so that abortion is not understood as a method of contraception. In view of the existence of illegal abortion, we demand suitable attention to women requiring hospitalization after an induced abortion.
6. Adequate attention in the prenatal, birth-giving and postnatal stages, and indictment of unnecessary surgery.
7. Urgent regulation of male and female sterilization to avoid the frequent abuses that occur at present.
8. Medical and psychological care for battered women and victims of rape and sexual violence.
9. Promotion of courses on human sexuality in schools of medicine and related fields.

In the second half of that same year, meetings became more frequent. In addition to the Feminist Discussion Forum (SP, monthly), and the Regional, Meeting of the Women of the Northwest (Natal, RN, September 1983), a national gathering of feminist groups was held in Campinas (SP) to discuss PAISM and to present the federal government with its criticisms and suggestions. The following are some of the conclusions:

The proposals presented by the government in the Integrated Women's Health Care Programme still have an interventionist perspective:

1. It is common knowledge that the Brazilian government believes there is an imbalance between economic and demographic growth and that this is a great problem for the country.
2. The precarious conditions of health care are also common knowledge, from the point of view of both material and human resources (shortage of doctors and nurses, low wages).
3. The programme is based on the recognition that women want to control their fertility by linking the regulation of fertility to an integrated women's health care programme. However, it does not discuss or establish the necessary conditions to guarantee women the right to a free choice between having and not having children.
4. An integrated women's health care programme can only reach all women if it is combined with social welfare policies and to laws that promote change in the distribution of incomes, of medical and educational services and of certain laws, and promote the conditions that make it possible for women to decide about their own bodies. If the current conditions of life and of medical attention are maintained, the programme's family planning could easily turn into birth control.

Apart from this, we do not agree with the premise that regulation of fertility is a problem of society and that it is the task of the government to alter demographic tendencies. The regulation of fertility is a private issue, and the obligation of the state is to offer information, technical know-how and infrastructure so that each individual may decide whether or not to have babies, how many and when.

Any programme that really offers the freedom to choose between conception and contraception must include the improvement and expansion of health services and understand health as closely related to the living conditions of the population. Nurseries and schools must be made available, laws that discriminate against the participation of women in society must be changed, and abortion must be legalized. The conditions necessary to change women's traditional role in society must be established so that conception and contraception cease to be the exclusive responsibility of women. In addition, research must be stimulated on other effective, reversible methods of contraception for men and women that are less harmful to health.

 

A programme that caters for all the needs related to women's health can only be effective if it does not isolate women from the economic, social and political context in which they live and if it takes into account their anxieties, fears, wishes and needs. For this, women must be heard and their organizations must be allowed to participate constantly and effectively in the discussion, decision-making and implementation of programmes related to them.

  

---------------------

PROGRAMMES

Integrated Women's Health Care Programme

Origins of the programme

Ministry of Health (1983) as a proposal for integrated and preventative health in connection with basic health services.

To whom the programme is directed

The programme is to be carried out on a national level, catering for the female population before, during and after the reproductive cycle.

Declared objectives of the programme:

General

Improvement of the level of women's health through the promotion, protection and recovery of health, before, during and after the reproductive cycle.

Specific

• Increasing the coverage and attention given during the prenatal stage.
• Improving the quality of assistance during birth, increasing the coverage of and reducing the number of caesareans.
• Promoting breastfeeding by opening nursery rooms.
• Implementing and/or increasing facilities for the detection and control of cervical, uterine and breast cancer and of sexually transmitted diseases.
• Developing regulatory activities on human fertility, implementing contraceptive methods and techniques, diagnosing and correcting infertility.

Commitments of the programme

• Basic health care with simplified and integrated activities.
• Integrated attention to women's health.
• Adherance to the population policies established by the Brazilian government in Bucharest (1974); each state should make available information and services on the regulation of fertility and adopt measures for the reduction of mortality, especially in infants.
• Official action to correct the distorted use of contraceptive methods through action at the state level in the field of fertility regulation, understood as a fundamental right of the individual.
• Discarding the ideology which views family planning as relevant to economic development.
• Legislation and regulation will be carried out by the ministry; execution will be left to state secretariats.

Programmed action

• Integrated and coordinated services related to: preventive gynaecological examination, gynaecological pathology, conception and contraception, prenatal assistance, assistance during birth and postnatal monitoring.
• Educational health activities in relation to sexuality, physiology of reproduction, means of fertility control, prevention of sexually transmitted diseases and of breast cancer, improvement of hygiene and diet and breast feeding.

Women's Health Programme

Origin of the programme

Sao Paulo State Health Secretariat (1983) as a proposal related to the basic health services network.

To whom the programme is directed

• General population of the State of Sao Paulo (male and female).
• General population, both with and without remunerated work and before, during and after the reproductive cycle.

General aims

• Improvement of the quality and widening of the basic health service network.
• Implementation of an integrated, regionalized, structured and simplified health system; improvement, enlargement and training of human resources.
• Improvement of health conditions.

Specific aims

- Making available high quality services for prevention, diagnosis, treatment and recovery in health programmes for women, in relation to work, socio-cultural context, reproduction and sexuality.

Commitment of the programme

• The improvement and expansion of the public sector's basic health network, simplifying, structuring and integrating activities with the health needs of the population in mind.
• Demystification of the ideological fallacies of pro- and anti-natalism; dissociation from demographic policies oriented towards the reduction or the increment and stabilization of fertility rates; avoiding hypertrophy and the isolation of activities related to contraception.
• Contributing towards improving and guaranteeing male and female freedom in deciding how many children to have and with what spacing, as well as in the use of contraception; contributing towards the equalization of male and female responsibility in reproduction.
• Programming monitoring and evaluating workgroups with the participation of other institutions.

Programmed action

• Health care in the prenatal, birth-giving and postnatal stages; gynaecological care; prevention of breast and uterine cancer, male and female infertility and sexually transmitted diseases; medical attention in conception, contraception, pre-adolescence, adolescence and menopause.
• Educational activities aimed at improving awareness in sexuality, parenting, breastfeeding, and the advantages and disadvantages of contraceptive methods, in order to maintain and enhance freedom of choice.
• Research on morbidity rates, among others.

Source: Canesqui, Ana Maria, "A saude da mulher em debate," in Revista Saude em Debate, No. 15/16, Center of Health Studies, February 1984.

---------------------

Feminists and Paism

In the article "Contraception: Our Everyday Drama" (Mulherio No. 17, July/August 1984), Ethel Leon sums up the position of many feminist groups regarding the implementation of government programmes:

"We are experiencing a complicated situation," says Maria Jose Araujo, a feminist doctor working in the Bela Vista Women's House and the Grajau Women's House in Sao Paulo. "I am aware of an enormous political backwardness in the systematic rejection of governmental health programmes. First we must ask ourselves if we are strong enough to withdraw these programmes from the scene, and what to do if they were withdrawn. Rejecting the programmes flatly leads nowhere. If the issue of contraception is taken up by government bodies, social pressure can be exerted by health groups and women's groups, demanding a policy that will effectively improve health conditions and ensure some degree of discussion on sexuality, which cannot be done if interventionist private agencies continue to monopolize contraception."

The Eva de Novo* group from the state of Goias has drawn up a document outlining the faults and contradictions of PAISM, in addition to criticizing its authoritarian formulation and the possible interventionist tendencies it contains. It is not that the group rejects the idea of family planning, but they conceive it under certain conditions which presuppose structural changes in Brazilian society. The Women's Union of Sao Paulo, on the other hand, proposes the wholesale rejection of the programme.

"It seems to me," says Maria Jose, "that we must emphasize an aspect that has not been considered up to now, which is the degree of popular participation in the programme. We must attempt to intervene in its implementation rather than continue to nag while the implementation goes on. Perhaps the idea would be to constitute a committee to oversee the family planning programmes, made up of political parties and of various entities, whose role, apart from denouncing any errors made, would be that of evaluation, presenting proposals and acting as spokespeople before government programmes. Finally, I do not believe that mere rhetorical rejection will contribute towards solving the dramas that women live in connection with contraception."

* In late 1984, this group, in spite of their reservations concerning PAISM, decided to work in its implementation. Their work includes promoting women's reflection groups in the hospitals of Goiania and criticizing the programme's implementation.

OTHER FEMINIST OPINION

Carmen Barroso, a feminist researcher on health and population, stated the following in an article published in the daily newspaper Folha de Sao Paulo dated 17 October 1984:

"This programme is based on a serious diagnosis that recognizes the grave health situation of the female Brazilian population and the terribly precarious state of the services that cater to it. Based on research, the diagnosis recognizes clearly the fundamental criticisms expressed by the women's movement and the health movement during the last two years: prenatal monitoring, when it exists, is of low quality; less than 2% of the female population has access to the prevention of cancer; the incidence of sexually transmitted diseases has increased; clandestine abortion is increasingly common; for lack of information and medical attention, thousands of women have used contraceptives indiscriminately and have been sterilized without considering the problems involved; adolescents have not been taken into account in health programmes and neither have women in menopause or those with fertility problems.

"In the general orientation of the programme, the controversial subject of family planning lies along the lines of the most progressive thinking of society: it does not attempt to be a solution to the country's social and economic problems, it forms part of an integrated health care system, it is not compulsory, and above all it is linked with educational activities oriented towards providing people the necessary knowledge to achieve a larger degree of control over their health.

"It is necessary to recognize that we are faced with an uncomfortable fact. A government that does not merit even a little of our sympathy presents a programme that corresponds with our needs and aspirations. If we do not have the courage to admit our discomfort with this situation, we will continue to be paralyzed, incapable of effective political action.

"We are facing real problems which the opposition should discuss more deeply. Everyone talks about passing from theory to practice. How will human resources be trained, in a way that provides not only the necessary technical qualifications, but also favours a radical transformation of attitudes to make it possible for women to be considered as whole, autonomous beings? How can the educational activities - by necessity brief and simple - be made participatory, respecting the experience of each individual?

How can these contribute towards making it possible for women to enjoy and look after their own bodies? How will contraceptives be bought or manufactured in the short, medium and long term? Where will resources be obtained to cover the shortages of the basic health network?

"Apart from technical aspects, these matters have an important political dimension, since the solutions proposed will depend, in order to be effectively implemented, on permanent and alert popular participation. The degree of mobilization is relatively small, and could be increased if the real problems that interest the population were widely discussed. This is the task of the opposition."

---------------------

Feminist Meetings on Women's Health Between 1980 and 1983

21-22 June 1980, Valinhos (SP): Meeting of Feminist Groups and Independent Feminists. The Committee for Family Planning and Birth Control was born at this meeting. Around 150 women took part. The committee produced the document entitled "Birth Control and Family Planning: No to the government's ambiguous and vague proposal."

March 1983, Rio de Janeiro: Women's Meeting on Health, Sexuality and Abortion, organized by the Rio de Janeiro Women's House, the Mulherando group, CERES and the IDAC Proyecto-Mulher. A nationwide campaign for the legalization of abortion in Brazil began after this meeting.

22 June 1983, Sao Paulo: Women's Health: Feminist Proposals, organized by the Women's Information Center (WIC), SOS Sao Paulo, the Politics and Sexuality group (now the Sao Paulo Feminist Sexuality and Health Collective), Pro-Mulher (Bela Vista Women's House), the Women's Union, the Feminist Women's Front, the Lesbian-Feminist Action Group and the Study Group of the Council on the Female Condition.

July 1983, Brasilia (DF): Fifth National Feminist Meeting, organized by Brasilia-Mulher, the Rio de Janeiro Women's Collective, the Rio de Janeiro Women's House, Brasil-Mulher/Salvador, the Grajau Women's House (SP), the Women's Information Center (WIC), the Center for the Defense of the Rights of Women (Belo Horizonte) and the Center for the Revaluation of Women (CEVAM, Goias). Sexuality, abortion, women's health and family planning were discussed. No final document was made, but WIC has available a transcript of the discussions.

September 1983, Natal (RN): Meeting of the Women of the Northwest, resulting in the document, "Feminist Proposals for a Human Reproduction Policy."

22 September 1983, Sao Paulo: Feminist Discussion Forum, resulting in the document, "Ours and Not Ours: A Feminist Position on Health, Sexuality and Abortion."

October 1983, Campinas (SP): Nationwide Meeting, carried out by the following groups: the Campinas Feminist Collective, the Campinas SOS-Women's Action, the Women of the Outskirts of Campinas Group, the Health Group of the Worker's Party (Campinas WP), the Campinas Center for the Defense of the Rights of Women, the Santo Andre Women's Association (AMUSA), the Women's Information Center (WIC, SP), SOS Mulher (SP), the Women's Discussion Forum (SP), feminist groups from Rio de Janeiro, assistants of the Deputy for Rio de Janeiro Lucia Arruda, SOS-Corpo from Recife and Brasilia-Mulher. The document drawn up is called, "Our Position on the Health Policy for Women."

7-8 July 1984, Sao Paulo: Sixth National Feminist Meeting. Ninety-seven people took part, including thirty-three feminist groups and institutional committees. Women's health and family planning were discussed. No final document was drawn up, but WIC has available a transcript of the discussion.

22 September 1984, Rio de Janeiro: Women and Reproductive Rights, promoted by the state deputy Lucia Arruda for the WP, and the State deputy Godofredo Pinto/PMDB, the first a feminist and the second a teacher. Three hundred women and fifty men took part.

17-19 October 1984, Rio de Janeiro: Educational Activities in Women's Health Care, promoted by UNICEF-Regional Programme for Women in Development (RPWD) and the Health Ministry-Integrated Women's Health Care Programme. Around 150 people took part, including feminist groups with experience in education in the field of women's health, as well as professionals and individuals working on women's health in Brazil.

20 October 1984, Sao Paulo: First Meeting on Women's Health in the Southern Zone, promoted by the Municipal and State Health Secretariat, the State Council on the Female Condition and the Women's Union of the southern zone. Around 400 women took part, mainly from the outskirts of Sao Paulo.

15-18 November 1984, Sao Paulo: First National Meeting on Women's Health, organized by the Bela Vista and the Grajau Women's House, the Sao Paulo Feminist Sexuality and Health Collective, the Family Counseling Service (FCS) and the Women's Information Center (WIC). Around 400 women from 19 states took part.

---------------------

Feminist Participation in the Implementation of Official Women's Health Programmes

Up to now, only a few women's groups have been community health groups are working directly in the implementation of official programmes at the federal and state levels. It is more common to find feminists working within government institutions of various states and capitals, such as Curitiba (PR), Rio de Janeiro (RJ), Florianopolis (SC), Salvador (BA), etc. We have selected a few examples of how this participation takes place, at the educational level.

In Goias: State Health Secretariat

The implementation of PAISM in Goias began to be discussed in 1984 by a group of only six people in charge of the project. According to Ana Costa, "the State Secretariat now has a team of thirteen people responsible for the coordination of work in women's health.

"We have introduced educational activities into routine health activities, and that is where the change in the position of professionals comes from. In group discussions, medical care is called into question and reclaiming our bodies is considered, as is space for women in medical consultancy. Contraception is talked of as a right. It is for this reason that doctors have begun to complain, saying women are talking too much."

In Sao Paulo: State Health Secretariat

For over a year, the Health Secretariat, through the Women's Health Group, has been organizing discussion groups on sexuality together with the technical and administrative staff of health centers in the capital and in the interior, on the basis of the sex education leaflets of the Carlos Chagas Foundation. Apart from the discussion groups, debates and seminars on the subject have been organized, some of which have been carried out together with the State Council on the Female Condition.

The Health Secretariat has determined recently that women's health would be top priority this year in health programmes for Sao Paulo, and has shown itself ready to discuss, with women's groups, the way in which they could take part in the implementation of health programmes.

In a meeting with the executive committee for the Women's Health Programme, the women's movement presented the Secretairiat with a proposal for monthly meetings to discuss the implementation of the programme step by step in the following aspects: sex education, training of technicians, policies for research on medicines and reproduction, abortion, etc.

The proposal was accepted. Discussions began in April 1985 and will continue until December 1985.

---------------------