Open Mike: The Elephant in the Room

It’s time to talk about the elephant in the room.

We cannot afford to ignore it any longer. It affects nearly every aspect of global health and will have a profound impact on our collective future if we don’t do something about it.

The elephant is population growth.

The world faces a plethora of great challenges: food insecurity, insufficient access to safe water, climate change, disempowerment of women, increasing numbers of deaths from natural disasters, emerging diseases and many others.

Underlying many of these challenges to public health is population growth. In 1950, the global population was about 2.5 billion people. Today, it is 6.9 billion. In just 10 years there will be 7.6 billion. But this growth is concentrated among the world’s poorer countries that, with their weak health systems, are least able to deal with future public health challenges. In the next decade, sub-Saharan Africa will grow from 863 million to 1.2 billion; that’s equivalent to adding the populations of the U.S. and the Netherlands. Such growth is simply unsustainable. It is a path that will lead us to a future of diminishing resources and increasing conflict.

More people mean less food, crowded cities, increasing populations vulnerable to natural disasters, and greater chances for new pathogens to jump from animals to humans. Larger families mean each child gets a smaller share of food, clothing, money for school fees and so on. Women who have more children have increased risks of mortality and reduced options for their own education and empowerment. We know that women who are empowered make good choices for the family, whether economic- or health-related.

Worldwide, more than 200 million women who want to delay or prevent pregnancy do not get the contraceptives they need. In sub-Saharan Africa, almost one-quarter of women who want to delay or stop childbearing do not have their demand for family planning services met. This issue obviously has significant implications for fertility rates, the average number of children born per woman. In Uganda, women want on average 5.1 children rather than the 6.7 they have. In Pakistan, they want 3.1 rather than 4.1. Bolivian women end up with 3.8 rather than the 2.1 births they want. Low-income countries like these are hurtling down an unsustainable path. Uganda’s population today is about 30 million. The Population Reference Bureau estimates its population in 2050 will be 117 million. Between my first trip four years ago to Uganda’s capital, Kampala, and my most recent visit, the differences were striking: more people, more traffic and more stress—both human and environmental. Urbanization is a factor, of course, but many cities around the world are straining to meet the basic needs of their inhabitants.

Some leaders in developing countries view a burgeoning population as a solution to their problems, an engine of economic growth. In reality, however, such growth means that children and the countries that they live in will not be able to reach their potential. Economies may grow, but needs will exceed production. The middle class needed to lead a country and make it prosper will not be created.

Clearly, it is not our place to tell people how many children to have, but we can help women and families who want access to family planning services so they can choose when to have children and how many to have.

Over the past few decades, family planning has faded from the global health agenda. The U.S. had been a leader in providing family planning services worldwide until the issue was linked with abortion and became mired in the nation’s culture wars. It is time to restart the discussion about population and to take action.

During family planning’s lean years, committed experts struggled on or left the field to work in other areas. In November, more than 1,300 of them gathered in Kampala for the first global family planning conference in more than 15 years. I cannot tell you how exciting it was to be present at this conference. The School’s Bill and Melinda Gates Institute for Population and Reproductive Health and Makerere University, a long-standing partner, organized the conference. They had expected 200 to 400 attendees but finally stopped registration at 1,200. On the day of the event, 180 unregistered people joined the other conference attendees who came from 61 countries. The atmosphere was electric. People were hungry for knowledge about family planning programs. Janet Museveni, the First Lady of Uganda, opened the conference with an inspirational talk that laid out the issues and the challenges ahead. Other presentations focused on strategies for meeting the unmet need for family planning. Amy Tsui, Gates Institute director, summed up the conference’s mood when she proclaimed, “Welcome back to family planning!”

The world is ready to take on the challenge. The Obama administration is returning family planning to the global health agenda. It rescinded the Mexico City “gag rule” that banned U.S. funding for international health groups that provided counseling about terminating pregnancies, and it has increased support for international family planning and reproductive health services.

Our role, as a school of public health, is to generate the evidence regarding population dynamics; determine the best, culturally sensitive strategies for family planning and other health care interventions at the individual and community level; advise governments and other organizations as a trusted partner; and, lastly, to train the next generation of leaders.

The elephant awaits.