That has been the pattern again and again: With the best of intentions, pro-life conservatives have taken some positions in reproductive health that actually hurt those whom they are trying to help--and that result in more abortions. Pro-choice and pro-life camps, despite their differences, should be able to find common ground and work together on many points, in particular on an agenda to reduce the number of abortions. Visit clinics in Estonia, where abortions were widely used as a form of birth control, where some women had ten or more abortions, and you see the resulting high levels of infertility and other complications. And in poor countries, abortions are sometimes as lethal to the mother as to the fetus. For every 150 unsafe abortions in sub-Saharan Africa, a woman dies; in the United States, the risk is less than 1 in 100,000. So liberals and conservatives should be able to agree on steps that prevent unwanted pregnancies and thus reduce the frequency of abortion.
Yet that doesn't happen. One of the scandals of the early twenty-first century is that 122 million women around the world want contraception and can't get it. Whatever one thinks of abortion, it's tragic that up to 40 percent of all pregnancies globally are unplanned or unwanted--and that almost half of those result in induced abortions. By some measures, more than one quarter of all maternal deaths could be avoided if there were no unplanned and unwanted pregnancies. It's an added disgrace that over the last dozen years there has been negligible progress in providing family planning, particularly in Africa. Only 14 percent of Ethiopian women use modern forms of contraception today.
"We've lost a decade," Professor John Cleland, a British fertility expert, told a parliamentary study group in 2006. "Contraceptive use in Africa has hardly increased in the last ten years in married women. It is a disaster."
Curbing population growth isn't nearly as simple as Westerners assume. In the 1950s, one pioneering family planning project in Khanna, India, sponsored by the Rockefeller Foundation and Harvard University, gave intensive help with contraception to eight thousand villagers. After five years, the birth rate among those people was higher than that of a control group given no contraception. Far more commonly, contraception programs have a modest effect in reducing fertility, but still less than supporters expect.
One carefully conducted experiment in Matlab, Bangladesh, found that after three years family planning programs reduced the average number of births to 5.1 in the target area, compared to 6.7 in the control area. That's not a revolution, but it reflects a meaningful impact. Peter Donaldson of the Population Council asserts that family planning programs accounted for at least 23 percent of the fertility decline in poor countries between 1960 and 1990.
The key to curbing population is often less a technical matter of providing contraceptives and more a sociological challenge of encouraging smaller families. One way to do that is to reduce child mortality, so that parents can be sure that if they have fewer children, they will survive. Perhaps the most effective way to encourage smaller families is to promote education, particularly for girls. For example, England slowed its fertility rate seriously in the 1870s, probably because of the Education Act of 1870, which called for compulsory education. That reflects a very strong global correlation between rising education levels and declines in family size. It appears that the most effective contraceptive is education for girls, although birth control supplies are obviously needed as well.
There's some evidence that decisions about childbearing reflect deep-seated tensions between men and women about strategies to pass on their genes. Polling tends to confirm what evolutionary biologists have sometimes suggested, that at a genetic level men often act like Johnny Appleseed, betting that the best way to achieve a future crop is to plant as many seeds as possible, without doing much to nurture them afterward. Given biological differences, women prefer to have fewer children but to invest heavily in each of them. One way to curb fertility, therefore, may be to give women more say-so in the family.
Quite apart from laying a foundation for economic development, family planning programs are also crucial these days in fighting AIDS. HIV is a special problem for women, in part because of biology: Women are about twice as likely to be infected during heterosexual sex with an HIV-positive partner as men are. That's because semen has a higher viral load than vaginal secretions do, and because women have more mucous membranes exposed during sex than men.
One of the greatest moral and policy failures of the last thirty years is the indifference that allowed AIDS to spread around the globe. That indifference arose in part from the sanctimony of the moralizers. In 1983, Patrick Buchanan declared, "The poor homosexuals--they have declared war against nature, and now nature is exacting an awful retribution." In retrospect, the grossest immorality of the 1980s took place not in San Francisco bathhouses, but in the corridors of power where self-righteous leaders displayed callous indifference to the spread of the disease.
One of the challenges in curbing the virus is a suspicion of condoms held by many conservatives. Many of them fear that even discussing how to make sex safer also makes it more likely; there may be an element of truth to that, but condoms unquestionably also save lives. Today, condoms cost two cents each when purchased in bulk and are extraordinarily cost-effective in reducing diseases. A University of California study suggested that the cost of a year of life saved through a condom distribution program was $3.50, versus $1,033 in an AIDS treatment program (admittedly, that was when AIDS medications were more expensive). Another study found that each $1 million spent on condoms saved $466 million in AIDS-related costs.
Yet even though condoms are so cost-effective, they are rationed with extraordinary stinginess. In Burundi, which the World Bank counts as the poorest country in the world, donor countries provide fewer than three condoms per man per year. In Sudan, the average man receives one condom every five years. Someday people will look back and wonder: What were they thinking?
Some critics of condoms began spreading the junk science that condoms have pores ten microns in diameter, while the AIDS virus is less than one micron in diameter. That is untrue, and evidence from discordant couples (where one partner has HIV and the other doesn't) suggests that condoms are quite effective in preventing AIDS, albeit not as effective as abstinence. In El Salvador, the Catholic Church helped push through a law requiring condom packages to carry a warning label declaring that they do not protect against AIDS. Even before the law, fewer than 4 percent of Salvadoran women used condoms the first time they had sex.
George W. Bush never signed on entirely to the anticondom campaign being waged by many within his administration, and the United States continued to donate more condoms than any other country, with mild increases over the years. Ironically, it was the Clinton administration (and a stingy Republican Congress at the time) that gutted American donations of condoms: from 800 million condoms donated annually during the George H. W. Bush administration to a low of 190 million in 1999. The George W. Bush administration donated more than 400 million condoms a year during its second term.
The Bush administration focused its AIDS prevention campaign on abstinence-only programs. There is some evidence that abstinence education can be helpful, when paired with a discussion of condoms, contraception, and reproductive health. But the Bush program went beyond underwriting abstinence education; it insisted on "abstinence only" for young people, meaning no discussion of condoms in schools (although the Bush AIDS program did distribute condoms readily to high-risk groups, such as prostitutes and truck drivers in Africa). Indeed, one third of AIDS prevention spending was funneled by law to abstinence-only education. One American-sponsored abstinence-only approach consists of handing out heart-shaped lollipops inscribed with the message: DON'T BE A SUCKER! SAVE SEX FOR MARRIAGE. Then the session leader invites girls to suck on the lollipops and explains:
Your body is a wrapped lollipop. When you have sex with a man, he unwraps your lollipop and sucks on it. It may feel great at the time, but, unfortunately, when he's done with you, all you have left for
your next partner is a poorly wrapped, saliva-fouled sucker.
Studies on the impact of abstinence-only programs aren't conclusive and seem to depend to some extent on the ideology of those conducting the study. But on balance, the evidence suggests that they slightly delay the debut of sexual activity; once it has been initiated, however, kids are less likely to use contraception. The studies suggest that the result is more pregnancies, more abortions, more sexually transmitted diseases, and more HIV. Advocacy groups like the International Women's Health Coalition fought heroically for evidence-based policies on sexual health, and Congresswoman Carolyn Maloney battled tenaciously for UNFPA programs, but the White House wasn't listening. Finally, President Barack Obama--shortly after taking office--announced that he would end the "gag rule" and restore full funding to family planning groups and to UNFPA.
One of the premises of the abstinence-only campaign had been that Africa's AIDS problem was a consequence of promiscuity, but that may not have been true, particularly for African women. Emily Oster, an economist at the University of Chicago, notes that about 0.8 percent of American adults are infected with HIV, compared to 6 percent of adults in sub-Saharan Africa. When she examined the data, she couldn't find any indication that Africans are more promiscuous. In fact, Americans and Africans report a similar number of sexual partners (although some experts believe that in Africa they are more likely to be concurrent rather than consecutive). The biggest difference, Oster found, was that transmission rates are much higher in Africa than in America. For any given unprotected sexual relationship with an infected person, Africans are four or five times more likely to get HIV themselves.
That higher rate can be explained in part because Americans get treated for genital sores; Africans often don't. At any one time, 11 percent of Africans have untreated bacterial genital infections, and these sores allow for easy transmission of the virus. Public health experts widely acknowledge that one of the most cost-effective ways to treat HIV is to provide free checkups and treatment for such STDs. Oster notes that when AIDS prevention resources are devoted to treating STDs, the cost per year per life saved from AIDS is only about $3.50.
In any case, for women the lethal risk factor is often not promiscuity but marriage. Routinely in Africa and Asia, women stay safe until they marry, and then they contract AIDS from their husbands. In Cambodia, a twenty-seven-year-old former prostitute told us of her struggles with AIDS, and we assumed that she had caught the virus in the brothel.
"Oh, no," she said. "I got AIDS later, from my husband. In the brothel, I always used condoms. But when I was married, I didn't use a condom. A woman with a husband is in much more danger than a girl in a brothel."
That's an exaggeration, but it underscores a central reality: AIDS is often a disease of gender inequality. Particularly in southern Africa, young women frequently don't have the power to say no to unprotected sex. Teenage girls, for example, often become the baubles of middle-aged men, and so HIV spreads relentlessly. As Stephen Lewis, the former UN ambassador for AIDS, puts it: "Gender inequality is driving the pandemic."
One test of a program should be how it handles the challenge of a fourteen-year-old girl like Thabang, who lives in the village of Kwa-Mhlanga in the northeastern part of South Africa. Tall, flirtatious, and liberal with makeup, Thabang is a rebellious adolescent who would be a challenge for any program. Thabang's father, an electrician, died after a protracted battle against AIDS that consumed the family savings. Thabang's mother, Gertrude Tobela, tested positive, apparently after getting the disease from her husband, and then infected her youngest child, Victor, during childbirth. Gertrude had been the first in her family to go to high school and college, and the family had enjoyed a middle-class standard of living. But soon Gertrude was too sick to work, and the family had to survive on $22.50-a-month government payments. The atmosphere in the shack in which they lived was despairing.
Thabang is smart and talented, and like any teenager she yearned for fun and warmth and love. She dreaded the misery of the shack, so she began to hang out in town. She had her hair done fashionably and wore sexy clothes, seeking the diversions of boys to escape the claustrophobia of her home. She also wanted more independence, yearned to be a grown-up, and resented her mother's efforts to rein her in. Thabang also has the misfortune of being strikingly attractive, so men flattered her with their attentions. In South Africa, successful middle-aged men often keep young teenage girls as mistresses, and many teenagers see such "sugar daddies" as a ladder to a better life.
When Thabang began flirting with men, Gertrude screamed at her and beat her. Thabang was the only member of the family who didn't have AIDS, and Gertrude was aghast at the possibility that Thabang would contract the virus as well. But Gertrude's beatings infuriated Thabang, confirmed the girl's suspicion that her mother hated her, and prompted her to run away. Thabang also seemed to feel embarrassed by her AIDS-ridden mother, weak and frail and poor, and all their fighting left Gertrude even more exhausted and depressed. Gertrude spoke in a composed way about her own imminent death and Victor's, but she broke down completely when she spoke of Thabang.
"My daughter left me because she wants liberty," Gertrude said, sobbing. "She is so sexually active, and she stays in bars and rental rooms." Gertrude looked upon Thabang's fondness for makeup and tight clothes with horror and couldn't bear the thought that the cycle of AIDS would be repeated in the next generation. For her part, Thabang insisted that while her friends slept with men for cash or gifts, she herself did not.
Thabang in front of the shack she dreads in South Africa, where her mother is dying of AIDS (Nicholas D. Kristof)
"I'm a virgin, whatever my mother says," Thabang said, and she began to cry as well. "She never believes me. She just yells at me."
"Your mother loves you," Nick told her. "The only reason she scolds you is that she loves you and cares what happens to you."
"She doesn't love me!" Thabang replied fiercely, tears trickling down her cheeks as she stood outside her home fifteen feet away from her mother, who was also crying. "If she did, she would talk to me instead of beating me. She wouldn't say these things about me. She would accept my friends."
There's no question that the local schools should encourage abstinence for girls like Thabang. But those programs shouldn't stop there. They should explain that condoms can dramatically reduce the risk of HIV transmission, and they should demonstrate how to use condoms properly. Governments should encourage male circumcision, which reduces HIV risk significantly, and should encourage free screening and treatment for sexually transmitted diseases. Testing for HIV should become routine, requiring people to opt out instead of to opt in. That way, nearly all adults would know their AIDS status, which is crucial, because it's impossible to contain an epidemic when people do not know whether or not they have been infected. That kind of comprehensive approach to prevention would be most effective in reducing the risks to a girl like Thabang. And these prevention methods are much cheaper than treating an AIDS patient for years.
Most of the studies on preventing AIDS aren't rigorous, but scholars at the Massachusetts Institute of Technology's Poverty Action Lab--which does some of the finest research on development anywhere--have examined four different strategies against AIDS in careful trials in Africa. Each strategy was tried in randomly chosen areas, and the results were compared to results in control areas. Success was measured by pregnancies averted (compared to the control areas), since they presumably reflected the amount of unprotected sex that could also transmit AIDS.
One strategy was to train elementary school teachers in AIDS education; that cost only $2 per student but had no impact on reducing pregnancies. A second approach was to encourage student debates and essays on condoms and AIDS; that cost only $1 per student but was not shown to reduce pregnancies. A third approach was to provide students with free uniforms to encourage them to stay in school longer; that cost about $12 per student and did reduce pregnancies. Using their comparisons with t
he control areas, the researchers calculated that the cost was $750 per pregnancy averted. The fourth and by far the most cost-effective approach was also the simplest: warning of the perils of sugar daddies. Schoolchildren were shown a brief video of the dangers of teenage girls going out with older men, and then were informed that older men have much higher HIV infection rates than boys. Few students had been aware of that crucial fact.
The warning didn't reduce girls' sexual activity, but they did end up sleeping with boyfriends their own age rather than with older men. The boys were more likely to use condoms--apparently because they were shaken by learning from the school presentation that teenage girls were much more likely than teenage boys to have HIV. This simple program was a huge success: It cost less than $1 per student, and a pregnancy could be averted for only $91. It's also a reminder of the need for relentless empiricism in developing policies. Conservatives, who have presumed that the key to preventing AIDS is abstinence-only education, and liberals, who have focused on distribution of condoms, should both note that the intervention that has tested most cost-effective in Africa is neither.
Religious conservatives have fought against condom distribution and battled funding for UNFPA, but they have also saved lives in vast numbers by underwriting and operating clinics in some of the neediest parts of Africa and Asia. When you travel in the poorest countries in Africa, you repeatedly find diplomats, UN staff, and aid organizations in the capitals or big cities. And then you go to the remote villages and towns where Western help is most needed, and aid workers are suddenly scarce. Doctors Without Borders works heroically in remote areas, and so do some other secular groups. But the people you almost inevitably encounter are the missionary doctors and church-sponsored aid workers.
Half the Sky: Turning Oppression Into Opportunity for Women Worldwide Page 17