5 April 2012

Africa: Melinda Gates - Tedxchange - the Big Picture

Photo: Bill & Melinda Gates Foundation
A mother plays with her young son in the Kenyan village of Mwea.


Prepared remarks by Melinda French Gates, co-chair and trustee:

I'd like to talk to you about a totally uncontroversial idea...which unfortunately has become incredibly controversial.

This year, well over a billion couples will have sex. This couple is one. So is this one. This one. This one, too.

My idea is this:

  • All these men and women should be free to decide whether they do, or do not, want to conceive a child.
  • And they should be able to use one of these birth control methods to act on their decision.

You'd have a hard time finding many people who disagree with this idea.

A billion people use birth control without hesitation. They use it because they want the power to plan their own lives and to raise healthier, better-educated, and more prosperous families.

But for an idea that is broadly accepted in private, birth control generates a lot of opposition in public. Some people think contraceptives are code for abortion, which they're not. Some people are uncomfortable because contraceptives have to do with sex. Some people worry that the real goal is to control populations. All these side issues have attached themselves to the core idea that men and women should be able to decide when to have a child.

As a result, birth control has almost disappeared from the global health agenda. The victims of this paralysis are the people of sub-Saharan Africa and the poorest parts of South Asia.

In Germany, the proportion of people currently using a modern contraceptive is 66 percent, which you might expect. El Salvador is also 66 percent. Thailand: 64 percent. Compare that to Uttar Pradesh, the biggest state in India, which would be the fifth biggest country in the world if it were a country: Its contraceptive rate is 29 percent.

Nigeria, the biggest country in Africa, is at 10 percent. Chad: 2 percent.

Let's look at one country, Senegal, where the rate is 12 percent. Why is it so low? The most popular contraceptive is rarely in stock. Most women in Senegal and across Africa use injectable methods, because they're easiest to hide from their husbands, who often want lots of children.

Women need an injection every three months, but every other time they go to the clinic, the shelves are empty. This situation is common across the continent.

This is a life and death crisis. Every year, 100,000 women who don't want to be pregnant die in childbirth. About 600,000 women who don't want to be pregnant give birth to a baby who dies in her first month of life.

I know everybody wants to save these mothers and babies.

But somewhere along the line, we got confused by our own conversations and we stopped trying to save these lives. We need to be clear about our agenda. It is not abortion. It is not population control.

We are talking about giving women the power to save their own lives and their children's lives--and to give their families the best possible future.

There are lots of things we have to do as a community to make a better future. Fight diseases like diarrhea and pneumonia that are killing millions of children. Help farmers on small plots of land grow enough food. Make sure all children are educated.

But one of the simplest and most transformational things we can do is give everybody access to the birth control methods that almost all Germans--and all Americans--use at some point in their lives.

As long as we are clear, I believe there is a global movement in waiting, ready to get behind this totally uncontroversial idea.

Your Story

I grew up in a Catholic home, and I am still a practicing Catholic. My mother's great uncle was a Jesuit priest. I was very close with my great aunt, who was a nun, a teacher, and a principal. When I was little, she's the one who sat with me and taught me how to read.

I attended Catholic schools every day of my life until I left home for college. At my high school, Ursuline Academy, the nuns made service and social justice a priority. In my work at our foundation, I believe I am applying the lessons I learned in school.

In the tradition of the great Catholic scholars, the nuns also taught us to question received teachings. One of the teachings most of my classmates and I questioned was the one saying that birth control is a sin.

I think one of the main reasons people are so uncomfortable talking about this issue is a lingering concern that separating sex from reproduction will encourage promiscuity. It's a reasonable question to ask about contraception: What is its impact on sexual morality?

But like most women, my decision about birth control had nothing to do with promiscuity. I had a plan for my future. I wanted to go to college, and I studied hard. I am proud that I was one of the very few female computer science graduates in my class. I also wanted to have a career.

I went to business school, and I became one of the youngest female executives at Microsoft.

I remember the day I left my parents' home to start work at Microsoft.

They had made a lot of sacrifices to pay for five years of higher education, but as I walked down our front steps to make my way in the business world, this is what they said to me: "If you decide you want to get married and have children right away, that's OK with us, too." They wanted me to do the thing that made me the happiest, and I was free to decide what that would be. It was an amazing feeling.

In fact, I didn't want to have children right away, but I did want very badly to have children...when I was ready. Now Bill and I have three. When our eldest was born, two years after we were married, we weren't entirely sure how to be parents. Some of you probably know the feeling.

We loved her so much, and we wanted to spend time learning how to be better parents before we had our next child. It's no accident that our three children are each spaced three years apart.

Now, the thing I want most in the world is for my children to feel the way I felt--like they can do anything they want to do in life.

Mary Ann's Story

The thing that strikes me most when I travel around on behalf of our foundation is that all women want the same thing. Last year, I met with a mother's group in a slum outside Nairobi. The women were taking turns explaining why they use birth control. Finally, a woman named Mary Ann summed up the whole conversation in a phrase I'll never forget. She said, quote, "I want to bring every good thing to one child before I have another."

That's universal. We all want to bring every good thing to our children.

What is not universal is our ability to provide every good thing to our children.

Many women in places where domestic violence is common cannot even broach the subject of contraception. Many more lack basic education.

Even for women who do have knowledge and power, getting access to the contraceptives they need can be a significant obstacle.

History Lesson

For the past 250 years, parents around the world have been deciding to have smaller families. This trend has been steady for a quarter of a millennium, across cultures and geographies. With the glaring exception of sub-Saharan Africa and a few places in South Asia.

The French started bringing down their family size in the mid-1700s, and over the next 150 years the trend spread throughout Europe. What surprised me was that it spread not along socioeconomic lines, but along cultural lines. People who spoke the same language made the change as a group, whether they were rich or poor.

The reason the trend toward smaller families spread this way is that it was driven by an idea--the idea that couples can exercise conscious control over how many children they have. This is very powerful. It means parents have the ability to affect their future, and don't just have to accept it.

In France, average family size went down every single decade for 150 years in a row before it reached a steady state. Part of the reason it took so long is that contraceptives weren't very effective two centuries ago. Here in Germany, the transition didn't start until the 1880s, but it only took 50 years before family size stabilized again.

In Asia and Latin America, the transition started in the 1960s, but it happened much faster because the contraceptives kept getting better.

It is important to pause while we're going through this history to remember another reason why this issue got so contentious. Some countries adopted unfortunate incentives or coercive methods as part of their family planning programs. For example, back in the 1960s, India set numeric targets for IUD insertions and then paid women to "accept." Some women got an IUD, collected six rupees, and then went immediately to a midwife to have it taken out at a cost of one rupee. For decades in the United States, African-American women were routinely sterilized without their consent, in a procedure nicknamed a "Mississippi Appendectomy." This is a tragic chapter in my country's history. As recently as the 1990s, in Peru, women from the Andes region were anesthetized and sterilized without their knowledge. The startling thing is that these coercive policies were carried out in places where parents already wanted to lower their family size.

Because in region after region, parents have again and again decided to have smaller families. There is no reason to believe that African women have innately different desires from the rest of the women in the world.

Given the option, they will bring their overall fertility down.

The question is, Will we invest in helping all women get what they want now, or will we condemn some to a century-long struggle--as if this were still revolutionary France and the best method available were coitus interruptus?

Impact on Development

Empowering parents needs no justification. But here's the thing. Our desire to bring every good thing to our children is a force for good throughout the world. It's what propels societies forward.

When I was in the slum outside of Nairobi, I met a young businesswoman who sold backpacks she made from scraps of denim. She had three children, and she and her husband had decided to stop at three. She told me it would be impossible to keep her business if she had to take care of another child. On the other hand, she said, with the money she was earning, she'd be able to send all three to school. She was optimistic about their future.

This is the same mental calculus hundreds of millions of women have gone through, and the evidence proves that these women have it exactly right.

They are able to give their children more opportunities by exercising control over when they have them.

In Bangladesh, there is a district called Matlab where researchers have been collecting data on 180,000 inhabitants since 1963. It may be the longest-running, most rigorous study in the field of global health.

As part of the study, half the villages in Matlab were randomly chosen to get easier access to, and extra education about, contraceptives. Twenty years later, the people in those villages had a higher quality of life than their neighbors.

  • They were healthier.
  • They were less likely to die in childbirth.
  • They were less likely to have a child who died.
  • They were better nourished.
  • They were also wealthier.
  • Adult women's wages were higher.
  • Households had more total assets--things like land, livestock, and savings.
  • Finally, their sons and daughters had about half a year of additional schooling.

When you multiply these effects times millions of families, the product can be large-scale economic development. A lot of people talk about the East Asian economic miracle of the 1980s. It wasn't exactly a miracle.

One of the leading causes of economic growth across the region was the fact that the culture shifted toward smaller families.

These trends start with individual families making decisions about what is best for their children, and they end as sweeping regional and national changes. When families in sub-Saharan Africa are given the opportunity to make these decisions, it will help spark a virtuous cycle of development in communities across the continent.


We can help poor families build a better future. We can insist that all families have the opportunity to learn about contraceptives, and have access to the full variety of methods so they can decide which one is right for them. That is the clear goal: universal access to the birth control that women want. To achieve that goal, rich and poor governments alike must make birth control a priority.

We can do our part by talking about the hundreds of millions of families that don't have access to contraceptives. We need to have a frank conversation about how it would change their lives if they did. Mary Ann and the members of her mother's group are able to have this discussion out in the open. We can, too. We need to start now.

As Mary Ann said, we all want to bring every good thing to our children.

Where is the controversy in that?

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