Bending the population curve

Hunger. Environmental degradation. Political instability. These were among the consequences of rapid global population growth documented in a five-part series in The Times in July. Now, Opinion has invited leading scholars to consider what, if anything, people and governments can do to address the issue. In the brief essays that follow, Malcolm Potts from UC Berkeley sets up the situation we are facing, and population experts from around the globe explain some of the approaches they’ve seen work -- and the reasons others have not. The series, by Times staff writer Kenneth R. Weiss and staff photographer Rick Loomis, can be found at


No one-size solution

By Malcolm Potts

Rapid population growth is at the center of many of the world’s pressing environmental, economic and security problems. Look at the images coming out of Gaza, Goma or Kabul, and you’ll see jostling crowds of men, most of them poor and without jobs. As the 9/11 Commission report concluded: “A large, steadily increasing population of young men without any reasonable expectation of suitable or steady employment [is] a sure prescription for social turbulence.”

In the Sahel, that dry strip of land bordering the Sahara’s southern edge, the crisis is already acute. In 1950, this region had 30 million people. Today there are 103 million. By 2050, climatologists predict that global warming will have greatly exacerbated the region’s problems. And if family planning continues to be neglected, the population of the Sahel by 2050 will have exploded to a totally unsustainable 340 million. Tens of millions of people will be forced to migrate in a humanitarian catastrophe that in the next 30 years could bring as much misery to the world as HIV/AIDS has in the last 30 years.

The antidote is family planning, which is not only a universal need but also a basic human right. It is not about telling people what to do; it is about listening to what women want. Having worked internationally for almost 50 years, I have learned that whenever women are offered a range of family planning methods, backed up by honest information about side effects, family size always falls. Smaller families mean that parents are able to keep their children in school and put enough food on the table. When family planning is made available on a wide scale, as in South Korea and Brazil, not only do birthrates fall but entire countries grow more prosperous.

But to be effective, family planning programs need to take cultural and religious norms into account. They can’t be coercive or insensitive, and must be tailored to specific needs. One size will never fit all. The ideas that follow remind us that, although contraception is as essential to modern living as the internal combustion engine or the microchip, there are still patriarchal individuals and institutions waiting to deny women their reproductive rights.


Malcolm Potts is a professor in the School of Public Health at UC Berkeley.


The Kulanjan lesson

By Gopi Gopalakrishnan

Two years ago, in Kulanjan village in the Indian state of Uttar Pradesh, we learned an important lesson. A local entrepreneur, working with the World Health Partners network, had organized an IUD service day, in which village women could obtain the birth control devices and have them inserted for just $3. It seemed an ideal opportunity for Kulanjan. Women could get inexpensive intrauterine devices, and the entrepreneur who organized the event would get about a dollar for each device sold. Some 80 women registered to come.

The day arrived, and a public-sector nurse from some distance away came to do the procedures. But the women had questions. The biggest one was this: “Where do we go for medical attention if we experience excessive bleeding or backache?”

That was when we realized our mistake. Our focus had been on providing and inserting the IUDs, and we had no plan in place for what would happen subsequently. As a result, only one of the dozens of women who turned out that day left with an IUD. The others were too concerned about how they would get follow-up care if it became necessary.

We reworked our project, arranging for a nurse to visit the village every two weeks. If a problem developed, clients could also consult with a doctor by cellphone or over the Internet. With these safeguards in place, the results were remarkable. Our program ended up providing eight times the IUDs and 31/2 times the number of sterilizations as comparable initiatives.

The lesson of Kulanjan was this: Of course low prices for family planning services are important, since fertility is highest among the poor. But women require predictable follow-up care and sensitive communication that explains side effects, especially for methods such as IUDs and injectable contraceptives.

Gopi Gopalakrishnan is program director for World Health Partners.


Better birth control

By J. Joseph Speidel and Kirsten Thompson

About 40% of the pregnancies in developing countries -- some 80 million each year -- are accidental.

Contraception is the obvious way to address unplanned pregnancy. But the currently available contraceptives all have limitations. Some 20% to 50% of married women surveyed in developing countries have said that unpleasant side effects, health concerns and inconvenience prevented them from using contraception, even though they would like to avoid pregnancy. Up to half of these women stopped using a contraceptive because they experienced or feared side effects. And the problem isn’t just in the developing world. About half of U.S. pregnancies are unplanned or mistimed, and about half of those are due to inconsistent or incorrect use of a contraceptive.

These statistics point out a need for better methods of preventing pregnancy.

The World Health Organization has recognized that it is extremely challenging for any human to regularly take medicine daily, which is probably why about 1 in 10 women using birth control pills becomes pregnant during the first year of use. We have only two highly effective and reversible contraceptives that don’t require ongoing vigilance: hormonal implants and IUDs, but neither is under the direct control of the user, since they require highly skilled healthcare providers for insertion and removal.

Research shows that there is demand for contraceptives that are user-controlled and do not require daily action for effectiveness. There is also demand for a contraceptive that would prevent the transmission of HIV. And there is a demand for more contraceptives that can be used by women without the participation or knowledge of others.

The public sector, including the U.S. Agency for International Development, the National Institutes of Health and the World Health Organization, have great track records on contraception research and development. They developed most of the contraceptives now available in the U.S. But funding for this work has steadily declined in the last 30 years, and large pharmaceutical companies have withdrawn from contraceptive research and development. Given the clear public health need and gaps in the types of contraceptives available, it is time to reverse this trend and restore funding for this important work.

J. Joseph Speidel and Kirsten Thompson are with UC San Francisco’s Bixby Center for Global Reproductive Health.


An integrated approach

By Leona D’Agnes and Joan Castro

Some problems are too deeply interconnected to be addressed separately. That was our experience in a remote and impoverished coastal region of the Philippines. Malnutrition and poverty had risen sharply in the area. Why? Because a rapidly expanding population was dependent on a badly depleted fishery and a coastal ecosystem that was being destroyed. We needed an integrated approach to the issues.

Working closely with community members to identify problems and strategies for addressing them, our team launched an intervention, helping local governments and organizations establish community-based family planning services and marine protected areas for the regeneration of fish stocks and mangrove forests. People of every age were involved. Programs aimed at young people encouraged postponing early sex and childbearing and taught environmental stewardship. Some adults were trained to intervene in illegal fishing activities that harm the marine environment, others to provide family planning information. Technological assistance and microloans were available for fishing-reliant families seeking other ways of earning a livelihood, such as beekeeping, food processing, seaweed cultivation or farming.

How did it work? Fertility fell, family income rose and coastal ecosystems began to come back. High birthrates are often an outgrowth of complicated factors, and overpopulation in turn generates its own set of problems. An integrated approach can be far more effective in addressing the full range of issues.

Leona D’Agnes is a technical advisor to and Joan Castro is executive vice president of PATH Foundation Philippines. D’Agnes is architect of the Integrated Population and Coastal Resource Management initiative and Castro is its program manager.


A strange silence

By Martha Campbell

A key reason we haven’t made more progress in curbing population growth is that for the last 20 years, almost no one has talked about it.

The strange silence, during a period when the world population grew from 5.5 billion people to more than 7 billion, has its roots in the “Earth Summit” in Rio de Janeiro in 1992. There, a number of activist women agreed that the International Conference on Population and Development, scheduled to be held in Cairo two years later, should broaden its focus to include a wider range of women’s concerns, including education, health and improved justice.

These are all worthy issues. But the tragedy was that a group of women’s advocates devoted themselves to making the terms “population” and “family planning” politically incorrect, suggesting that focusing on numbers of people somehow invited coercive family planning that was aimed at preventing women in developing nations from having children they wanted. This was absurd, since the vast number of family planning programs focused on enabling women to make their own decisions. But after the Cairo conference, due mainly to the unfortunate silence, international family planning budgets collapsed.

The results have been predictable. Kenya, for example, which had brought average family size from eight children per woman to 4.5 children with an excellent and completely voluntary family planning program, couldn’t sustain its progress when funding began to dry up. As a result, Kenya will have an estimated 12 million more people in 2050 than it would if family planning support had remained stable.

But there is finally some encouraging news. This year, exactly 20 years after the Rio summit, at the London Summit on Family Planning, Melinda Gates and a number of world governments decided to break the silence and put family planning back on the agenda. After two decades of silence, sensible people can finally unite in condemning both coercive family planning and the coercive pregnancies that result when women are denied access to family planning. Hundreds of millions of women around the world have paid a terrible price for the silence that began 20 years ago. They have been forced to have larger families than they wanted, giving up on other goals for themselves and their children as a result. We must never again be silent.

Martha Campbell is a lecturer at UC Berkeley and the president of Venture Strategies for Health and Development.


Success in Iran

By Djavad Salehi-Isfahani

In the 1980s, Iran had among the highest birthrates in the Middle East, with the average Iranian woman bearing seven children. In less than two decades, the fertility rate had dropped to two children per mother, setting a world record for the speed of fertility transition.

There are lessons to be learned from Iran’s turnaround, which was completely voluntary and occurred under a conservative Islamic government that had initially helped spark a baby boom by restricting opportunities outside the home for women.

Three factors help explain Iran’s success in winning the population, including the rural poor, over to family planning.

First, five years before beginning to advocate smaller families, the government started building rural clinics across the country. By the time the call came for smaller families, women had come to trust their health providers and were thus more likely to accept family planning advice when it was offered.

A second reason for Iran’s success is that the government trained and employed young local women as health workers. They knew the clients they served and could act as role models.

And third, the health system was active rather than passive. If a married woman failed to show up at the clinic at least once a year, a health worker visited her at home.

Once women signed on to family planning, they saw the benefits, including greater opportunities for themselves and their children. But it’s too early to declare victory. This fall, Iran’s supreme leader, Ayatollah Ali Khamenei, begged forgiveness from God for having gone “too far with family planning.”

Djavad Salehi-Isfahani is a professor of economics at Virginia Tech and a nonresident senior fellow at the Brookings Institution.


Pop culture’s role

By William N. Ryerson

As important as contraceptive supplies are to limiting population growth, they are only part of the story. We also need to address why people aren’t using birth control, even when they have access to it.

Surveys reveal that many couples in the developing world want far more than two children. In Nigeria, for example, the average married couple wants eight children. Other reasons people don’t embrace contraception include fear of health effects, spousal opposition, religious opposition and a belief that God should determine the number of children a woman has.

This situation requires education to help people understand the health and economic benefits for them and their children in limiting and spacing births. It requires modeling good family planning and overcoming fears and cultural taboos. It requires getting husbands and wives to talk to each other about contraception.

To address the cultural and informational barriers to smaller families, our organization, Population Media Center, produces locally written radio and TV serial dramas in which key characters embrace such things as family planning, schooling for girls and other social and health goals unique to each country.

The shows are gripping and entertaining, but they are also educational, and there is strong evidence of dramatic results in the 45 countries in which our programs have aired. For example, in northern Nigeria, where our radio serial was heard regularly by more than 70% of the population, a study found that about two-thirds of those seeking contraception cited the program as a motivating factor. Those who listened to the program also reported wanting fewer children. In Rwanda, listeners were 50% more likely than non-listeners to want three or fewer children. And during the 2 1/2 years our program aired in Ethiopia, 40% of listeners reported using modern contraceptive methods, compared with 25% of non-listeners.

Motivational communications, when accompanied by access to family planning services, work. We need to make this combination a high priority.

William N. Ryerson is president of the Population Media Center.


Religion as an asset

By Carl Pope

To tackle population issues, we need to address the things that hold women back: poverty, lack of education and patriarchy. One impediment to tackling these problems can be religion. Each of the world’s great spiritual traditions has misogynistic elements and hierarchical institutions that have been used to keep women subservient and backward.

So how can population planners address these issues without being culturally insensitive? By embracing religion.

The world’s religions all have scripturally authentic counterweights to misogyny, traditions that emphasize inclusion and dignity for all believers. These egalitarian religious strands are under assault from rule-based, hierarchical fundamentalism on the one hand and from cosmopolitan, dismissive urban elites on the other. But they hold the key to displacing traditional attitudes that have kept women oppressed.

Bangladesh stands as an example of the role religion can play in empowering women. The country has made substantial progress in shrinking the average family size, while at the same time embracing greater social influence and freedom for women. And the gains came not from displacing traditional Sufi Islam but by leveraging it. In Africa, too, embracing rather than dismissing religious traditions has led to gains for women. The modest successes to date in eliminating the barbaric (and un- Islamic) practice of female genital cutting, for example, have been rooted in educating women about authentic Islam.

In many societies, the pursuit of economic progress has been sufficient, when combined with modern medical services, to unleash the forces of empowered women and girls. With rare exceptions, those societies have already embraced the idea of smaller families and stable, even shrinking, populations. What remain are the hard cases. We will fail if we continue to ignore the importance of embracing the inclusive forces within a country’s religion as a core strategy to reverse the demographic spiral these societies face.

Carl Pope, former chairman and executive director of the Sierra Club, now works on projects at the intersection of sustainability and economic development.


Support from the top

By John F. May

In order for family planning efforts to be truly effective, they need a strong commitment from top leaders in the country. In Africa, where population pressures are particularly acute, many leaders have been reluctant to address the issue squarely. They have claimed, despite overwhelming evidence to the contrary, that Africa is underpopulated and that high fertility rates and larger populations make countries stronger. Some African leaders have expressed resentment for what they see as Western intrusion into their sovereignty.

Other African leaders, however, have embraced the need for action, and their countries are the better for it. Rwandan President Paul Kagame, for instance, is keenly aware of the implications of rapid population growth for the development prospects of his country. As a result, he has rekindled efforts to bring fertility levels down, with fair success so far. In the process, the Rwandan people -- particularly women and children -- have reaped significant health benefits.

The experience of East Asia has demonstrated that faster demographic transitions, including rapid declines in fertility, bring a demographic dividend: a period of fast economic growth. This economic growth occurs because declining fertility levels result in more productive people relative to dependents in a given population.

The demographic dividend could be a transformative tool for African countries too. But first, African leaders will have to embrace sound population policies. Without support from the top, family planning efforts in Africa will continue to struggle. It is the responsibility of African leaders to help their countries benefit from the demographic dividend.

John F. May is a visiting fellow at the Center for Global Development.


Preventing child deaths

By Rajiv Shah

Each year, 6.9 million children will die before they turn 5. Today we have the tools and knowledge to end preventable child death, an accomplishment that would not only be a great moral victory but also an essential part of addressing the world’s population challenges.

It may sound counterintuitive, but child survival and demographics are deeply connected. In country after country, we have seen families willingly choose to have fewer children when they know each will have a chance to survive and thrive.

The demograpic and economic benefits of child survival and voluntary family planning are clearly visible. Some of the fastest-growing economies in East Asia and Latin America were among the poorest just decades ago. These countries made important decisions in the 1960s and 1970s to invest in voluntary family planning, reducing child mortality and education.

Certainly, we need to address the existing unmet need for all women to have access to the contraceptives of their choice. But we also need to help them gain confidence that the children they have will live to adulthood. That’s what is required in order for families in the world’s poorest regions to understand the importance of voluntary family planning. By focusing on a range of life-saving interventions -- from bed nets that protect against malaria to new vaccines against diarrhea and pneumonia -- we can make it far more likely that children will live to celebrate their fifth birthdays.

Under the leadership of President Obama, USAID co-hosted a call to action on child survival that has resulted in more than 150 governments, including our own, signing a new pledge to end preventable child death. Already, through new public-private partnerships, companies are reducing the prices of key commodities to help us reach this goal.

Rajiv Shah is administrator of the U.S. Agency for International Development.