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THE STATE OF INTERNATIONAL FAMILY PLANNING IN 2005
PLANNED PARENTHOOD OF PORTLAND, OREGON
MARCH 16, 2005
REMARKS OF ALEXANDER SANGER
THE STATE OF INTERNATIONAL FAMILY PLANNING IN 2005
In the midst of international crises—Iraq, Iran, Korea, the Tsunami, HIV/AIDS in Africa—just to name a few, the central role of demographic and population concerns to the well being of the planet threatens to be forgotten, overlooked or ignored. We at Planned Parenthood tend to focus on lowering fertility and giving women the means and services to do this. Over the past two decades some researchers and policy makers in the demographic arena have tended to focus on the population and fertility decline in many countries of the world, rather than on the continuing high fertility in some developing countries. The implications of smaller families and impending population decline in Europe is by now old news, the implications being fewer workers, reduced economic growth, if any growth at all, and the need for increased immigration to pick up the slack and pay pension benefits to workers who now retire at age 60 or earlier. We are seeing the beginnings of the same story here as our President tries to drum up public support for a “social security crisis” caused by fewer workers being available to make the payroll tax payments necessary to support our elders in the years ahead. Immigration “reform” is never far from the political agenda in America or in other developed countries, nor is emigration in developing countries with its attendant brain drain and loss of productive workers but offset by cash remittances home that are a major source of local GNP. Population growth and decline are spread unevenly around the planet and in many parts of the world population growth is proceeding upwards at a rapid rate. There are also other demographic issues that cannot be overlooked—-an imbalance in the sex ratio, abnormally high death rates in some countries due to AIDS, just to name two. What is a planet to do?
The MDGs
The United Nations began a process in the early 1990’s to improve the wellbeing of the people on the planet which resulted in the adoption by the General Assembly in 2000 of the Millennium Declaration followed by the eight Millennium Development Goals, the MDGs. The Millennium Development Goals summarize the development goals agreed on at international conferences and world summits during the 1990s. In September of this year, world leaders are coming together again at the Millennium Summit in New York to discuss not just the MDGs but also a 3-part agenda: a) to review the achievements towards the Millennium Declaration (which is far more comprehensive than the MDGs; b) to discuss terrorism and security issues, and c) to discuss UN reform. The MDGs, therefore, are just a small part of the overall agenda of the meeting.
The Millennium Development Goals, to be achieved between 1990 and 2015, include:
- halving extreme poverty and hunger
- achieving universal primary education
- promoting gender equality
- reducing under-five mortality by two-thirds
- reducing maternal mortality by three-quarters
- reversing the spread of HIV/AIDS, malaria and TB
- ensuring environmental sustainability
- developing a global partnership for development, with targets for aid, trade and debt relief
An ambitious list to be sure, and as Gordon Brown, the Chancellor of the Exchequer in the UK said a month ago, in many countries the goals won’t be achieved until 2215 if then.
You will note that there is no specific MDG for sexual and reproductive health, a circumstance that was deliberate, though not acquiesced in initially, by the IPPF and concerned governments around the world. The UN goal was to have a consensus of goals that every government could sign on to and in the UN world this means to be as plain vanilla and as non-controversial as possible, at that same time as having a real and needed problem to tackle and alleviate. Any specific mention of sex and sexual and reproductive health would immediately bring up the hot button issues, including access to safe and legal abortion and adolescent services, which the UN tries desperately to avoid, usually unsuccessfully, witness last week’s fiasco to which I will return.
But, that said, you will note that sexual and reproductive health are integral to the attainment of virtually all the goals outlined above. This has been noted by the panelists of the Millennium Project who are in charge of creating benchmarks to assess how well we as a planet are doing on the MDGs. Reducing child mortality, improving maternal health and combating HIV/AIDs cannot be attained without improvements in access to sexual and reproductive health. Of course, gender equality is what we at Planned Parenthood have stood for from the beginning and which we incorporated into the Cairo Accord of 1994 and this will lead to not just increased gender equality and improvement of the status of women but in increased primary education for girls. All this will lead, hopefully, to a reduction of extreme poverty, and increased environmental sustainability within a global plan for development as women are given more economic opportunity.
What are also hidden and not explicit in the MDGs are demographic concerns. The list itself of MDGs is in many ways a personal wellbeing list. The list can be summed up as improved nutrition, health and survival, with improved education and economic opportunity. It is not a list of global political crises to be solved—less war and civil conflict, fewer nuclear weapons, provide for old age security, increase religious tolerance—-just to name a few that are not on the MDG list, but which are part of the Millennium Declaration. It is a plan for development, and many donor governments and aid recipients are together developing plans to achieve the MDGs. The goal is to increase official development assistance (ODA) and debt relief. The U.S. as usual is marching to its own drummer.
The dangers here are many—too ambitious goals that will lead to donor/taxpayer fatigue. But also there is a concern that the avoidance of explicitly having demographic benchmarks within the MDGs will lead to other world issues and crises not being addressed.
World Population Issues
The world population is at 6.4 Billion. The UN estimates that it will increase to 9 Billion in 2050. This estimate will change. The inevitable strain on the environment-—higher energy use, clean air and water, pollution, runaway development, deforestation, species extinction-—are harder to change.
The world population increases at about 75 million a year. About 190 million women get pregnant every year. There are about 45 million abortions and about 20 million miscarriages and thus125 million babies are born of whom about 4 million die within 30 days. About 45 million other people die every year giving a net increase of about 75 million a year.
Most of this 75 million increase, and the total increase to 9 billion by 2050, is in developing countries. The estimate a few years ago was in the 12-15 billion range. People’s reproductive behavior can change and change rapidly. In recent decades, and centuries when we consider the onset of the so-called demographic transition in 1750, there has been a sharp decline in family size. The average family worldwide has fallen from about 6 children in 1960 to under 3 children now. The latest world TFR, total fertility rate, is 2.7 and heading down.
| Region/Nation |
TFR |
Under Mortality M/F
per 1000 births |
Modern CC Prevalence |
| |
| World |
2.7 |
81/81 |
54% |
| More developed nations |
1.5 |
10/9 |
55 |
| Less developed |
2.9 |
89/89 |
54 |
| Least developed |
5.1 |
165/156 |
|
| |
| Uganda |
7.1 |
154/139 |
18 |
| Yemen |
7.0 |
100/95 |
10 |
| Ethiopia |
6.1 |
181/165 |
6 |
| Pakistan |
5.0 |
121/135 |
20 |
| Saudi Arabia |
4.5 |
26/23 |
29 |
| Kenya |
4.0 |
125/110 |
32 |
| Bangladesh |
3.4 |
85/90 |
43 |
| Egypt |
3.3 |
52/44 |
54 |
| India |
3.2 |
78/90 |
43 |
| Iran |
2.3 |
39/39 |
56 |
| |
| China |
1.8 |
39/47 |
83 |
| Latin America |
2.5 |
45/36 |
62 |
| Haiti |
4.0 |
119/104 |
21 |
| Guatemala |
4.4 |
58/51 |
31 |
| Peru |
2.9 |
57/47 |
50 |
| Mexico |
2.5 |
37/31 |
58 |
| Brazil |
2.2 |
52/39 |
70 |
| |
| USA |
2.1 |
8/9 |
71 |
A few notes. Both Bangladesh and Pakistan had a TFR in 1981 of 6.3. Bangladesh is now at 3.4 and Pakistan is at 5.0. All of Europe, except Albania, is under 2.0. France and Ireland are the highest at 1.9. Bulgaria, Estonia and Russia bring up the rear at 1.1.
You can see the relationship that fertility declines as infant mortality declines and contraceptive prevalence increases.
The Demographic Dividend
Is demography important in attaining the MDGs? The demographic transition, caused by reducing both birth and death rates, leads to a demographic dividend. This is caused by there being fewer dependents at the high and low ends of the age range, fewer old people to support (because modern medicine didn’t reach the older adult population until it was too late for many) and fewer children born (because of family planning). With more of the population in the economically productive years, the nation can invest more in economic development rather than in social security. Investment can also be made in health care and a better education system. This raises the standard of living of all, increases per capita income, reduces maternal mortality and income, increases child survival and health and allows girls and women especially to be educated and economically productive. These are the clear results of lower fertility in general which get multiplied during the demographic window.
A 2001 study of 45 countries found that that if these countries had reduced births by 5 per 1000, or _ of 1%, it would have reduced the national incidence of poverty of 18.9% in the mid-1980s to 12.6% in 1995.
The United States in some ways is still stuck in a mid-1980s mind set. One study by the National Research Council in 1986 found that population growth had little of no impact on economic growth. This clearly isn’t so.
The Asian Tigers made use of the demographic window. Not all Latin American countries did. Brazil and Mexico have seen faster growth through declining fertility, but many Latin nations did not take advantage and the demographic window will close when the ratio of dependents rises without a higher standard of living being attained.
Why is there high fertility? Because people like children and want to reproduce. Children are not just a biological asset, they are an economic one, on farms and for old age security. People often have more children than they want because of lack of access to contraception and because they have more than they need as insurance against high infant mortality rates. Fertility rates come down when children become liabilities instead of assets, when child survival rates go up, when women get educated and enter the workforce and marry later, and when contraception is supplied. Urbanization and industrialization are major factors in declining fertility. The demographic transition is unexplainable in a classic Darwinian sense since as people get wealthier they should be having more children. There are clearly other factors at work, including increased cost of children and perhaps the effects of crowding.
The Need for Family Planning and SRH Services
The UN estimates that 200 million couples are still in need of modern family planning methods and that 400 couples lack a full range of family planning methods. One half of pregnancies are unintended here and abroad.
There are 5 million new HIV cases a year and 340 million new STD cases a year.
There are 529,000 maternal deaths a year, 95% are in sub-Saharan Africa and South Asia.
40% of women given birth without a skilled birth attendant.
There are 46 million abortions a year, 20 million are under unsafe conditions and there are 67,000 fatalities.
The World Health Organization tried to figure out how to prioritize the steps to take to improve the health of people on the planet. Let’s see if there is a connection between what the WHO said and the MDGs, and how nations are allocating their foreign aid.
The WHO came up with a measure called DALYs, or disability adjusted life years. This measures shortened life span and productive span caused by disease. The ten leading risk factors globally are: underweight; unsafe sex; high blood pressure; tobacco consumption; alcohol consumption; unsafe water, sanitation and hygiene; iron deficiency; indoor smoke from solid fuels; high cholesterol; and obesity. Together, these account for more than one-third of all deaths worldwide.
The leading causes of DALYs are:
|
All |
Women 15-44 |
| Communicable diseases |
20% |
|
| SRH |
18% |
32% |
| Neuro-psychiatric |
13% |
25% |
| Injuries |
12% |
|
| Respiratory illness |
11% |
|
| Cardiovascular |
10% |
|
The SRH breakdown to total 18% is:
|
All |
Women 15-44 |
| Childbirth illness including unsafe abortion |
2% |
13% |
| Perinatal, including low birth weight |
7% |
|
| HIV |
6% |
14% |
| Other SRH |
3% |
5% |
|
18% |
32% |
Interestingly for women of reproductive age neuro-psychiatric illness causes 25% of DALYs and SRH causes 32%.
In terms of global risk factors for death, underweight is closely followed by unsafe sex, the main factor in the spread of HIV/AIDS, with a major impact in the poor countries of Africa and Asia. The WHO report says HIV/AIDS is now the world’s fourth biggest cause of death. Currently 28 million (70%) of the 40 million people with HIV infection are concentrated in Africa, but epidemics elsewhere in the world are growing rapidly. The rate of development of new cases is highest in Eastern Europe and central Asia. Life expectancy at birth in sub-Saharan Africa is currently estimated at 47 years; without AIDS it is estimated that it would be around 62 years.
Current estimates suggest that more than 99% of the HIV infections prevalent in Africa in 2001 are attributable to unsafe sex. In the rest of the world, the 2001 estimates for the proportion of HIV/AIDS deaths attributable to unsafe sex range from 13% in East Asia and the Pacific to 94% in Central America. Globally, about 2.9 million deaths are attributable to unsafe sex, most of these deaths occurring in Africa.
Funding for Reproductive Health Care
Total population assistance (a different figure than SRH but closely related) for 2002 was $3.2 Billion. The donors were:
| Source |
Amount |
| Donor Countries |
$2.3 Billion |
| Private Foundations |
$460 Million |
| Development Banks (loans) |
$328 Million |
| NGOs |
$70 Million |
While impressive, the donor countries are falling far short of what the Cairo Accord called for. The goal that Cairo set was that ODA, i.e. foreign aid, would be 0.7% of GNP. The average figure for donor countries is 0.4%. The U.S. is at 0.14%, way below the goal, even though in dollar terms it is the largest donor. It contributes about $440 million in family planning and reproductive health and additional $500 million for HIV, maternal and child care for a total in 2002 of $963 million. Most of it is now given to governments and as bilateral aid and less to NGO’s.
Development assistance has changed markedly over the last decade. Now, thanks to the UN process which culminated in the MDGs, countries, both donor and recipient, are engaged in poverty reduction strategies using country wide or sector wide approaches. Secondly, health sector reform is a key component of the country-wide approach whereby nations are improving their primary care systems in order to provide all the health care that its people need, including SRH. Most funding now is bilateral aid to a nation pursuant to a plan that has been negotiated in advance with donor countries, the UN, and the World Bank and other development banks. Less aid is flowing through NGOs.
If one were to allocate funds via disease burden and cost effectiveness of prevention, it would seem that prevention of communicable diseases would be the first target and SRH the second, assuming that prevention is cost effective. The MDG relating to HIV also calls for combating malaria and TB, two of the communicable diseases.
Are SRH prevention programs cost effective? The cost varies widely depending on the setting.
| Condition/disease |
Cost per DALY |
| Family planning |
$15-$150 |
| STI/HIV |
$1-$250 |
| Breast/cervical cancer |
$50-$100 |
| Iron deficiency/Vitamin A Iodine |
$5-$20 |
| Malaria |
$5-250 |
| Dengue Fever |
$1600-$3500 |
Where do donor countries allocate their foreign aid or Overseas Development Assistance (ODA)? On average, 4% goes to SRH. The U.S. is the lead donor by percentage to SRH at 7.3%. The 4% (or 7.3% in the case of the U.S.) allocated to SRH compares with 18% of the disease burden that SRH represents.
The Global Gag Rule
The Global Gag Rule prohibits US population funds in the foreign aid budget from going to any foreign NGO, i.e. IPPF, that with its own money either performs abortions, except in cases of rape or incest or to save the life of the woman, or counsels or refers for abortion, or lobbies to make abortion legal or more available in their country. Foreign NGOs that forego U.S. population assistance because they violate the GGR also lose access to contraceptive supplies, including condoms, and technical support from USAID.
The GGR does not apply to other U.S. foreign aid, at least directly. So, U.S, foreign aid for HIV/AIDS, for maternal and child health, for child survival and other health programs are not subject to the GGR. The GGR also does not apply to foreign governments.
This is the major loophole. The IPPF affiliates in Kenya for instance are subject to the GGR but the government of Kenya is not. Thus when IPPF Kenya and the Marie Stopes Clinics refused to sign the GGR, they lost their U.S. population assistance funds and closed 5 clinics so far. But the funds are eligible to go to the government of Kenya, which, if it wanted to, could fund the IPPF Kenya or could legalize abortion or counsel for abortion it its own clinics. However, anecdotally we hear that there is pressure from the U.S. depending on the region and country not to allow this to happen. AIDS funds as part of the U.S. foreign aid budget dwarf the population assistance account and there is no GGR attached. However, we hear again there is pressure not to allocate AIDS funds to organizations that do not sign the GGR. There is also further pressure not to allow linkage to SRH programs, which defeats the purpose of health sector reform and having the primary care system provide comprehensive services. There is also pressure not to work with sex workers and gay groups, major sources of HIV transmission. When you mix morality with public health you get a public health disaster.
We can document clinic closings, staff reductions and fewer services provided. But we have not yet documented the results for women, children and families. We have the same problem with the time the previous Global Gag Rule was in effect from 1984 to 1992. There is a clear need for research here. Our opponents say that people will cope. It is argued that if people can’t go to IPPF, they will go to the government health clinics, they will use traditional methods, they will reuse condoms, they will change sexual practices (they don’t say this out loud). In India and in Africa the current supply of condoms allows for about 3 or 4 condoms per year per man.
UNFPA Services
The UNFPA, United Nations Population Fund, is the leading vehicle for family planning assistance in many countries. The United States defunded UNFPA in 2001 to the tune of $34 million and every year thereafter based on allegations, proved to be unfounded, that UNFPA assisted in forced sterilization and abortion in China. One might wonder why UNFPA does work in China at all and why China can’t fund its own family planning programs. China donated $800,000 last year to UNFPA and received about $5 million in assistance.
Last year, 149 countries contributed to UNFPA and the agency did work in 136 countries. The total income was $400 million with Netherlands being the leading donor at $70 million and Japan number two at $40 million. Ireland contributed $2 million and Afghanistan contributed $100.
The spending was allocated mostly to Africa and Asia. Among the recipients:
Bangladesh $21 million
Guatemala $10 million
Mozambique $9 million
Nigeria $6.5 million
India $6.8 million
Peru $1.5 million
Other Demographic Issues
There are many factors that make up the world’s demographic picture. Mortality rates are half the picture. Life expectancy has been increasing for the last century though now it is plummeting due to HIV/AIDS and other health crises in sub-Sahara Africa and the states of the former Soviet Union.
| Life Expectancy |
Males |
Females |
| World |
63 |
67 |
| More Developed Countries |
72 |
79 |
| Least Developed Countries |
48 |
50 |
| Latin America |
67 |
74 |
Even with the burden of maternal mortality, women on average survive men by 4 years, 2 years in the least developed nations and 7 years in the most developed.
Women’s and girl’s education has been a particular target for population policy makers and health experts, the theory being that educated women will marry later, have fewer children, will contribute economically and be healthier. There has been remarkable progress and by some measures girls are doing better than boys in the education department.
| Education measures |
Males % |
Females % |
| Enrollment Grade 5 |
|
|
| Ethiopia |
63 |
59 |
| Rwanda |
39 |
41 |
| Tanzania |
76 |
80 |
| Zambia |
79 |
75 |
| |
|
|
| % Illiterate over age 15 |
|
|
| Kenya |
10 |
21 |
| Mozambique |
38 |
69 |
| |
|
|
| Secondary School Enrollment |
|
|
| Philippines |
78 |
86 |
| Malaysia |
66 |
73 |
| India |
56 |
40 |
| Iran |
79 |
75 |
| Pakistan |
29 |
19 |
| Saudi Arabia |
73 |
65 |
| Yemen |
65 |
27 |
In Latin America, in every country, except Bolivia, Guatemala and Peru, female secondary school enrollment exceeds the male enrollment. In the U.S. college enrollment is tilting heavily female.
Demography and State Failure
There would seem to be case enough for the wealthy nations of the world to support sexual and reproductive health care in developing countries-—health, population growth, education. The attainment of the MDGs cannot happen without sexual and reproductive services being part of the mix.
But what of the goals that we would all share for the planet, things like peace and the reduction of conflict?
The CIA over the past decade has been looking at the failure of nations and has a State Failure Task Force. There are three factors that can predict state failure, revolution and war. In reverse order of predictive ability they are lack of free trade, lack of democratic institutions and the number one predictor of the failure of a state, a high infant mortality rate. Experts are hard at work trying to figure out why a high infant mortality rate is such a good predictor of a nation. My own pet theory is that the ability to have the children we want and to have them survive is why we created governments and civil society eons ago and, when our government fails us in this regard, it is immediately illegitimate and must fall and be replaced.
Other experts are looking at the infant mortality rate as the other side of the coin of the demographic transition which occurs when births and deaths fall. Those nations with a high infant mortality rate have a high birth rate and thus they are at the beginnings of their demographic transition. States that have not begun the demographic transition are more likely to experience unrest than states that have gone through the transition. Estimates are that nations in the early phase have a 40% chance of unrest and civil conflict and in the later stages just 5%. Among other theories of increased chances of way are a youth bulge in the 15-29 age group, urbanization (1/2 the people on the planet now live in urban areas), competition for water and farmland and general ethnic tensions.
One theory of this is that smaller families cannot afford to send their sons (mostly) off to war. Their lives cannot be risked unnecessarily because that threats the continuance of the family line.
This gets complicated by a sex ratio that goes into imbalance. The sex ratio is the ratio of males and females in a society. There are two ratios, one at birth and one for the society as a whole. Mother Nature provides an imbalance at birth of 105/100, meaning that 105 boys are born for every 100 girls. This is nature’s way of compensating for more boys dying prematurely than girls for a variety of reasons-—being less robust and being greater risk takers. When through sex selection abortion and through female infanticide, abandonment and discrimination the sex ratio gets out of line, then there are a lot more males than there ought to be. China has come to this with its One Child Policy and families favoring the male child for their social security and to work the land. Korea and India came to it without a formal one child policy. In parts of Asia the sex ratio approaches 120/100 or more in certain locales.
The result is the same. This means that in a nation like China, or Korea or India, there are millions of men who are not going to be able to find a wife, settle down, have a family and have a stake in the community. They are a danger to the security of the nation. Some experts have said that the only solution is to export them, co-opt them by putting them in the military or other occupations away from the center of the nation’s life like coal mines and building dams, or kill them (perhaps a reason for China not robustly attacking the AIDS crisis). Excess males in the military are not a comforting prospect in troubled areas of the world—China/Korea, and India/Pakistan.
Special Country Crises—Russia
We cannot ignore other health challenges. Look at Russia for instance. Russia meets most of the MDGs with its high education levels and low infant and maternal mortality. But it is imploding demographically. It is facing not just a decline in fertility (now 1.1) but a high death rate from injuries and from poor health due to alcohol and drug abuse, AIDS and cardiovascular illness. Smoking, poor diet, sedentary lifestyle and vodka are the leading causes, and violence. Women normally die far less from violence than men, but the death rate due to violence for Russian women is higher than the death rate from violence for European MEN.
There is no immigration to take up the slack. There are 170 deaths for every 100 live births in Russia, about a million a year excess for the past 5 years. 13% of Russian couples are infertile involuntarily, compared to 7% in the USA, the result of STDs and botched abortions (hence my recommendation to bring RU-486 to Russia). Syphilis is 100 times greater than in Germany, and 10-20% of Russian women are rendered infertile after abortions. Russia had 3 divorces for every 4 marriages, a divorce rate higher than Scandinavia.
There is a direct connection between a healthy population, a productive population and national GNP. A Russian 20 year old has a 46% chance of reaching age 65, compared with 79% chance for an American 20 year old. As Nicholas Eberstadt has said, how can Russia sustain an Irish standard of living when its population has an Indian rate of survival? What does this mean for the Russian military and for global security where Russia might be a stabilizing force as in the Far East?
The U.S. and the MDGs
Over the past two weeks delegates from around the world met at the UN to measure progress on the agreements reached at the Fourth World Conference on Women in Beijing in 1995, and to make sure these commitments, as with those reached in Cairo, are firmly part of the MDGs. There were reports on women’s progress in legal status, equality, economic opportunity, sex trafficking, and so on. But the U.S. made sure than the conference was tied up with its assertions that there was no right to abortion in the Beijing Declaration and that there were no new other human rights in it either. The rest of the world disagreed, forcefully. I recall Hillary Clinton saying in Beijing that “women’s rights were human rights”. The Beijing declaration may not have been “new”, but it was a clarion call, as was Cairo, to put women front and center in population, health and development policies.
Since 2001 the United States has increased its foreign aid budget and its HIV/AIDS budget as well. None of the new foreign aid in the Millennium Challenge Account, some $5 Billion a year (though less has been asked for and appropriated), which is dependent on developing countries improving their governance and development policies, reducing corruption and increasing their openness to trade, had been disbursed. The new AIDS funding has been, but with the requirement that 1/3 be allocated to abstinence education. When one follows the infection pattern in most developing countries, it follows the trucking routes and areas of prostitution and then gets brought home to the travelers wives. This pattern is not conducive to abstinence education, and is a giveaway to “faith-based” organizations and is a waste of money.
The U.S., one can only say deliberately, lost an opportunity to build a domestic consensus last week for more foreign aid to help the world attain the MDGs. By its anti-abortion red herring, it diverted national opinion away from the MDGs to abortion and tarnished the UN in the process. This was a great disservice to humanity.
Alex Sanger
3/21/05
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All text and images © 2004 Alexander Sanger, All Rights Reserved. Any reproduction without expressed permission is strictly prohibited.
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