Population Matters

Secretary Clinton, the Global Health Initiative, and Family Planning

August 18th, 2010

During a speech Monday at the Johns Hopkins School of Advanced International Studies, Secretary of State Hillary Clinton asked an important question: “What exactly does maternal health, or immunizations, or the fight against HIV and AIDS have to do with foreign policy?” The answer she gave of “everything” shows how central global health is to the Administration’s thinking on international affairs.

Eighteen months ago, the Obama administration unveiled a $63 billion Global Health Initiative (GHI) to save millions of lives by expanding current programs and improving health systems in developing countries. The GHI, which has become a centerpiece of the Administration’s foreign policy, provides increased funding for HIV/AIDS, malaria, maternal and child health, family planning, neglected tropical diseases, and other critical health areas.

For starters, the GHI will increase the funding for PEPFAR, the President’s Emergency Plan for AIDS Relief. PEPFAR is a Bush Administration initiative that has provided millions of people with prevention and treatment services. The GHI will build off the successes that PEPFAR has had with antiretrovirals. Currently there are 5 million people in the developing world who are using antiretrovirals; the GHI seeks to reach 12 million people, including 5 million orphans and vulnerable children.

With 2.7 million new infections each year the GHI will also make sure that PEPFAR puts more focus on prevention. As Secretary Clinton said, “If we are going to win this war, we need to get better results in prevention.” PEPFAR, she said, will move beyond the “abstinence, be faithful, and consistent and correct use of condoms” (ABC) approach adopted by the Bush Administration.  She called for an “A to Z” approach that will take a more comprehensive approach to sexual and reproductive health.

The GHI also calls for making the U.S. a leader in family planning and maternal and child health. Currently, a woman dies every minute and a half due to pregnancy related causes and another 20 women suffer major injury.

Secretary Clinton made clear that family planning must play a leading role in the GHI:

Saving the lives of women and children requires a range of care, from improving nutrition to training birth attendants who can help women give birth safely. It also requires increased access to family planning. Family planning represents one of the most cost-effective public health interventions available in the world today. It prevents both maternal and child deaths by helping women space their births and bear children during their healthiest years. And it reduces the deaths of women from unsafe abortion.

Another major goal of the GHI is to increase integration of services so that people do not have to go to multiple clinics to receive different treatments. Currently a woman may have to go to one clinic to get her HIV/AIDS treatment, another one to get health care for her children, and another one further away for contraceptive supplies. This ‘siloed’ approach, as Secretary Clinton emphasized yesterday, has failed.  “Women we save from AIDS will die in childbirth. Children we save from polio will die from rotovirus.”

By integrating programs, the GHI is looking to produce a measured and sustained reduction in maternal and infant mortality and a qualitative improvement in the health of women and children. With adequate funding, including more funding for international family planning, the GHI can save lives and make a world of difference.

Full text and video of Secretary Clinton’s speech is available here.

Posted by Jennie Wetter, Program Manager

Reproductive Health When Disaster Strikes

August 13th, 2010

Mudslides, floods, and earthquakes have struck this year to disastrous effect. Early this year a powerful earthquake devastated Haiti and more recently there have been mudslides in China and record flooding in Pakistan. These well-publicized disasters have displaced millions of people, but there are many more around the world who have fled lesser known conflicts, disasters, and persecution.

Currently there are about 40 million such refugees. When disaster strikes, the initial focus is often on finding food and housing, but refugees have needs much greater than just food and shelter, especially when the average length of displacement is17 years. International relief agencies must address all of their requirements, including their reproductive health needs. Children still need school, people still need health services, and women still give birth or want to prevent becoming pregnant.

In Sub-Saharan Africa 6-14% of women and girls age 15-49 will be pregnant at any given time and in any population 15% of those pregnancies will have unforeseen complications. Lacking access to family planning supplies, women develop unwanted pregnancies, particularly where rape is prevalent. As a consequence, many women turn to unsafe abortion. But without access to basic reproductive health care, common and easily treated complications can become deadly.

That’s why it’s essential to provide reproductive health services, and quickly, to refugees. In the wake of a disaster, displaced populations should have access to the Minimum Initial Service Package (MISP) for reproductive health, which is the international standard for care as laid out in the IASC Health Care Cluster Guide and the SPHERE Humanitarian Charter and Minimum Standards in Disaster Response. The MISP gives women access to emergency obstetric care, safe birth kits, precautions against HIV infection, and contraceptives. MISP services prevent and respond to sexual violence, and should also lay out a long term plan for providing more comprehensive reproductive health care once the initial emergency has passed.

The MISP has been implemented in Haiti, and recently CARE, International Planned Parenthood Federation, Save the Children and Women’s Refugee Commission did an evaluation, called “Four Months On: A Snapshot of Priority Reproductive Health Activities in Haiti”. The report finds that while reproductive health services are a recognized priority, and coordination of MISP services has improved, challenges remain in Haiti. Specifically, more work was needed to prevent and respond to sexual violence, expand coverage of services, and raise public awareness of MISP services.

It is important that we build off the successes and lessons learned in Haiti to effectively address the reproductive health needs of refugee populations in China, Pakistan, and elsewhere in the world. Life doesn’t stop when an emergency or disaster strikes. Neither should reproductive health services.

Posted by Jennie Wetter, Program Manager

Only One Planet

August 12th, 2010

Stephen Hawking, the world renowned physicist, created a bit of stir this past week when he suggested, in effect, that humankind’s only hope is to abandon Earth.  He fears, as many do, that we are wrecking our planet so swiftly that unless we begin colonizing other planets with 100 or 200 years, humankind will be on the path to rapid extinction.

Our population and our use of the finite resources of planet Earth are growing exponentially, along with our technical ability to change the environment for good or ill. But our genetic code still carries the selfish and aggressive instincts that were of survival advantage in the past. It will be difficult enough to avoid disaster in the next hundred years, let alone the next thousand or million. Our only chance of long-term survival is not to remain inward-looking on planet Earth, but to spread out into space.

With large swaths of Russia in flames, major flooding in Asia, and giant icebergs breaking off of Greenland, this is no time to lose focus on planet Earth.  With all due respect to Hawking, outer space is not an option.  It’s been more than three decades since humans last walked on the moon, and the prospect of humans setting foot on Mars keeps on receding.  Before we head to the interplanetary lifeboats, we had better refocus our attention on saving the mother ship.

In the cosmic scale of things, the investments required to save planet Earth are not large. If we can just set aside the equivalent of what we spend on beer every year (about $300 billion) for things that might actually save the planet–like family planning, child nutrition, re-forestation, energy conservation, and renewable energy–we would have a fighting chance.  Spending another$3-4 billion a year on international family planning assistance, alone, would make a world of difference, but Congress has yet to act on the mere $67 million increase requested by the President for next year.

Reducing carbon emissions will not be easy, but it need not be terribly costly.  The proceeds from a stiff carbon tax could be rebated to taxpayers by a cut in payroll taxes, holding consumers largely harmless, but Congress this year refused to nibble on a far less ambitious cap-and-trade proposal.  So climate change legislation is dead, even though the deleterious effects of climate change are becoming all too real.

If Congress is concerned about the fate of the planet, it’s not evident. Maybe members of Congress think, like Hawking, that we can all book a seat on the first flight to Alpha Centauri. But with nearly 7 billion humans on the planet, most of us will have to stay home and make do with the mess that we are creating. 

Dimitar Sasselov, a top-ranking astronomer, recently announced that the Kepler Telescope, launched last year by NASA, has so far detected 150 Earth-sized planets, and that there may be 100 million Earth-like planets in our galaxy.  If there’s intelligent life out there, let’s hope that it exhibits more intelligence than we do.

Posted by Robert J. Walker, Executive Vice President

Not So Easy

August 6th, 2010

The writers and editors at Nature this past week boldly proclaimed, with some carefully qualified caveats, that producing enough food for the world’s population in 2050 will be easy. 

Maybe not.  Sending humans to the moon and safely returning them to the Earth is easy.  Been there, done that.  Feeding 9 to 9.5 billion people or more by 2050?  Not so easy. We’ve never done that.  And there are good reasons to believe we might not be able to.

Let’s take a closer look at what the writers at Nature said, and do a little dissecting.

In 2009, more than 1 billion people went undernourished — their food intake regularly providing less than minimum energy requirements — not because there isn’t enough food, but because people are too poor to buy it. At least 30% of food goes to waste.

Scientists, like everyone else on this planet, need to differentiate the theoretical from the economical and the practical.  If, as a result of grain embargoes by Russia and (possibly) Ukraine, the price of bread doubles this year, the impact on the world’s urban poor–many of whom are living on less than $1.25 a day–will be devastating.  And it matters not whether wheat reserves are rotting in India or whether Russia and Ukraine have surplus wheat. And it doesn’t matter how many bread crumbs we discard. 

The dictates of the marketplace can be brutal. There is plenty of money in the world, far more than is needed to eliminate severe poverty, but severe poverty persists.  In a global economy, where people’s ability to feed themselves depends on the cost of rice or bread, hunger can exist on a wide scale, even if there is plenty of food–in theory–to go around.

Don’t believe that?  Take a look at what’s happening today in the African Sahel. Last month, Josette Sheeran, the executive director of the World Food Programme (WFP), warned that, as a consequence of widespread hunger, Niger was in danger of “losing a generation.”  She said that the development of children under the age of five in Niger will be severely impaired unless food relief arrives soon. WFP plans to reach 4.5 million people in the region in the next few months, but Sheeran warned that the situation is deteriorating rapidly and that WFP needs about $100 million to bridge the funding gap. 

Here’s what Nature said about the last global food crisis:

The 2008 food crisis, which pushed around 100 million people into hunger, was not so much a result of a food shortage as of a market volatility — with causes going far beyond supply and demand.

Wrong.  During the 2007-8 food crisis the prices of wheat and corn doubled, while the price of rice tripled.  Why?  Because the world’s grain reserves during that period fell to the lowest levels in several decades. While market volatility may have contributed in some small measure, food production was not keeping up with demand.  When grain reserves grow dangerously low, speculators will always drive up prices. Scarcity always does.

Here’s what Nature said about projected population growth:

Scientists long feared a great population boom that would stress food production, but population growth is slowing and should plateau by 2050 as family size in almost all poorer countries falls to roughly 2.2 children per family.

Not so fast. The highly respected Population Reference Bureau estimates world population is currently 6.9 billion and that it will reach the 7.0 billion mark next year. It projects that world population will be just shy of 9.5 billion by 2050.  And the U.S. Census Bureau projects that world population, at that point, will still be expanding by more than 40 million people a year.

The writers at Nature say:

Producing enough food in the future is possible, but doing so without drastically sapping other resources, particularly water, will be difficult.

That’s an understatement. In many parts of the world today food production is already sapping water resources and water prospects for mid-century, particularly in many parts Asia, are not good.  Two months ago, the Strategic Foresight Group, a think tank based in India, released a report titled ‘The Himalayan Challenge: Water Security in Emerging Asia,” which concluded that India and China will face drops in the yield of wheat and rice anywhere between 30-50% by 2050.  At the same time demand for food grains will go up by at least 20%.”

The writers at Nature, however, suggest that technology may be the answer:

Many countries can make gains in productivity just by improving the use of existing technologies and practices.

But as the editorials writers at Nature took pains to note, “…increasing today’s brand of resource-intensive, environmentally destructive agriculture is a poor option.”  Instead, they call for investments in what they term “sustainable intensification,” so that farmers can generate greater yields using less water, fertilizer, and pesticides.

And, who knows, they may be right.  If the U.S. and other countries follow China’s example and ramp up their investments in sustainable agriculture, we might yet avert a widespread famine.  But that’s a big if.  And there are no guarantees that all the research in the world will produce a “second green revolution.”  

It all comes down to this. It may be theoretically and even economically possible to feed 9.5 billion at mid-century, but we shouldn’t bet the farm that we will.  And we certainly shouldn’t bet the fate of the world’s most severely impoverished. 

The editors at Nature say that the “investment throughout the agricultural chain in the developing world must double to US$83 billion a year.” I fully endorse that recommendation.  But what about boosting international family planning assistance by one or two billion dollars?  The need is certainly there. The U.N. estimates that there are more than 200 million women in developing countries who want to prevent an unwanted or unintended pregnancy, but who are not using modern methods of birth control. Educating and empowering women in developing countries and giving them the power to control their own fertility could go a long way toward making sure that the world can feed itself in 2050.  But, I suppose, that would be too easy.

Posted by Robert J. Walker, Executive Vice President

Family Planning Cuts- Not Just a Global Issue

August 6th, 2010

In response to the global recession some of the major donor nations have trimmed back their support for international family planning assistance. But cuts are also happening here at home.

Last Week, New Jersey’s Governor, Chris Christie, cut funding for state-wide family planning programs. He vetoed a bill that would have restored $7.25 million in funding for women’s health services, thus eliminating state funding for 58 family planning centers. According to the Philadelphia Inquirer, Christie was the first governor to make such steep cuts in family planning.

The Family Planning Association of New Jersey reports that:

New Jersey’s family planning centers last year provided reproductive and preventive health care to 126,903 women and 9,461 men, most of them without health insurance…The clinics provide low-cost birth control, breast exams, pap smears, screenings for sexually transmitted diseases, and prenatal care.

In the rural areas of New Jersey, which boast high levels of cervical cancer, teen pregnancies, and STDs, clinics worry that many women who lack health insurance will not be able to travel long distances to get the services they need.

Governor Christie cited deficit concerns and overspending in vetoing the bill, but providing family planning services actually saves money in the long run. A Guttmacher Institute report estimates that publicly funded family planning services in 2006 helped women avoid 1.94 million unintended pregnancies, which would have resulted in about 860,000 unintended births and 810,000 abortions.  The services also saved both federal and state governments $5.1 billion in 2008.  Every $1 invested saved $3.74 in Medicaid expenditures.

The state legislature can still override Christie’s veto, which would require 54 votes in the 80-member Assembly, and 27 votes in the 40-member Senate.  If 13 Assembly members, who abstained on the first round of voting, support an override of the Governor’s veto, family planning supporters believe they can successfully override the veto.

Family planning saves lives and, in the long run, it also saves money.  It’s a no-brainer.

Posted by Emily Pontarelli, Program Associate

Two “Must Wins” for Women

August 5th, 2010

With the August Congressional recess just days away, it’s time to check in on two pieces of legislation of vital importance to women in developing countries. 

The first is the International Violence against Women Act (IVAWA).  An estimated one out of three women in the world has been beaten, coerced into sex, or otherwise abused in her lifetime.  In some developing countries, the rate of domestic violence reaches or exceeds 70 percent. 

 IVAWA would establish an Office for Global Women’s Issues in the State Department to coordinate efforts regarding gender integration and empowerment of women in U.S. foreign policy.  At USAID, it would establish an Office for Women’s Global Development to integrate gender in U.S. foreign assistance programs and policies, and direct the agency to develop a comprehensive five-year strategy for programs to prevent and respond to violence against women and girls in countries with severe levels of violence against women.

 The House bill (H.R. 4594) was introduced by Rep. Delahunt and currently has 118 cosponsors.  The Senate bill (S. 2982), introduced by Senator John Kerry, has 31 cosponsors.  The Senate Foreign Relations Committee was scheduled to consider the bill earlier this week, but the “mark-up” was postponed at the last moment.  No action has been taken on the House bill, which was referred to both the House Armed Services Committee and the Foreign Affairs Committee.

The second is the International Protecting Girls by Preventing Child Marriage Act (H.R. 2103, S. 987), which was introduced in the House by Rep. Betty McCollum and in the Senate by Senators Richard Durbin and Senator Olympia Snowe. Child marriage is a recognized violation of human rights, but an average of 25,000 girls a day become child brides, and unless something is done to change this trend within the next 10 years, over 100 million girls in the developing world will become child brides. 

The legislation authorizes the President to provide assistance to prevent the incidence of child marriage and promote the educational, health, economic, social, and legal empowerment of girls. The State Department is required to come up with a multi-year strategy to prevent child marriage and promote the empowerment of young girls who are at risk of child marriage. Last month, the Human Rights Commission held a compelling Congressional hearing on the issue of child marriage, but no action has been taken as yet by either the House Foreign Affairs Committee or the Senate Foreign Relations Committee.

Momentum has been building for both of these legislative initiatives, but the Congressional clock is ticking. There are probably fewer than 25 legislative days remaining before Congress leaves town in October, and while a lame duck session this year is virtually assured, it may be difficult to pass these bills when Congress resumes in late November.

Empowering women in developing countries may not rank as high on the Congressional agenda as job creation, but the issues of violence against women and child marriage are of crucial importance to millions of women around the world.  While President Obama and Secretary Clinton have demonstrated outstanding leadership on these issues, they need the support of Congress now, not next year when a new Congress is sworn in. In Congressional parlance, these bills are not a “heavy lift.”  But they would provide a big lift to women in the developing world.

Posted by Robert J. Walker, Executive Vice President

Pakistan, Population, and the Flooding

August 2nd, 2010

The recent flooding in Pakistan that has killed an estimated 1500 people and left more than a million people homeless has nothing to do with population. Or does it?

The flooding, of course, has been caused by torrential rains, but deforestation is often a major contributor to flooding in the developing world.   Such is almost certainly the case with respect to the North West Frontier (recently renamed Khyber-Pakhtunkhwa) Province, which is one of the most densely populated and fastest growing regions in Pakistan.  Deforestation is a critical problem in many parts of Pakistan, but particularly in the NWFP, where subsistence farmers are heavily dependent upon trees for fuel and lumber. A 2006 report on deforestation in Pakistan found that: 

Forest depletion is one of the most serious environmental issues for Pakistan.  According to an estimate 39 thousand hectares of forests are vanishing annually.  Between the years 1990 and 2000, the deforestation rate in Pakistan was 1.5% annually (FAO, 2005). Studies based on remote sensing show that the rates of decline in forest cover in NWFP will lead to a complete disappearance of the forest from most areas within 30 years.

The report, which focused on the NWFP, noted that:

The winter season is very harsh with heavy snowfall and the people have no other option except to use forest wood for cooking and heating purpose. With the average household size of more than 9 persons the demand for firewood and fuel wood is increasing rapidly thereby adding enormous pressure on already degraded forests.

The region’s population, which has grown from 11 million in 1981 to an estimated 21 million today (not counting an estimated 1.5 million Afghan refugees), is largely rural and heavily dependent on agriculture, but the urban population is now rapidly growing as people are finding it more difficult to survive off the land.

Five weeks ago, population growth was apparently the subject of intense debate in the region’s legislative assembly.  According to a news report, PML-N member Javed Abbasi said that rapid population was the root cause of the prevailing social and economic problems being faced by Pakistan. Mufti Kifayatullah, a member of the rival MMA party, reportedly dismissed that assertion saying that, “The more children are born, the more Mujahid (jihadists) would be there.”

You don’t have to be worried about jihadists to be concerned about a desperately poor region that is suffering yet another humanitarian disaster.  Emergency aid will help to limit the suffering from this disaster, but unless more is done to expand family planning services in this region and elsewhere in Pakistan, the death toll from natural disasters like this one will only rise in the decades ahead.

Fortunately, Pakistan’s new federal government is strongly committed to expanding family planning services and information, but whether it will be successful in regions like this one remains to be seen.

Posted by Robert J. Walker, Executive Vice President