Martha M. Campbell, Ph.D. Center for Entrepreneurship in International Health and Development (CEIHD) School of Public

1. Fertility, Development and the Politics of Population Martha M. Campbell, Ph.D. Center for Entrepreneurship in International Health and Development (CEIHD) School of Public Health, UC Berkeley

3. A progression… 1 billion 1800 200,000? years 2 billion 1930 130 years 3 billion 1960 30 years 4 billion 1975 15 years 5 billion 1987 12 years 6 billion 1999 12 years

4. A contentious subject • Why? • Involves sensitive subjects – including sex and traditional values around reproduction • At least tough ethical questions, rarely examined • Causality hard to define in a complex system

5. Confusion • …between 2 Qs: “is population a problem?” and “what reduces fertility?” • Caution, fertility has two meanings: • Demography: how many children a woman (or a couple) has • Biology: whether a living being is able to produce offspring • …between necessary and sufficient.

6. A range of positions • Population and poverty: • Population Growth and Economic Development: Policy Question. US National Research Council of the National Academy of Sciences, 1986 • Population Matters: Demographic Change, Economic Growth, and Poverty in the Developing World.Nancy Birdsall, Steven Sinding, Allen Kelley, Oxford University Press 1991 • Population and environment: “Obvious” vs. doubts – or math: • “Ecological footprint”, “overshoot”, Mathis Wackernagel, Redefining Progress • Nile - Ethiopia/Sudan/Egypt…China, water tables

7. Population Summit of the World’s Scientific Academies New Delhi,1993 “If current predictions of population growth prove accurate and patterns of human activity on the planet remain changed, science and technology may not be able to prevent irreversible degradation of the natural environment and continued poverty for much of the world.”

8. Defining the Schools of Thought around the Earth Summit at Rio, 1992 • Influential in international policy arena • Common objectives and beliefs • Line up behind their more vocal proponents

10. VTC WIN POP MKT DST

11. W P P W P P P Asymmetry in the population policy arena POP MKT DST WIN VTC Primary interests Issues re population Chosen policy actions Beliefs Subjects not included \

12. W P P W P P P Asymmetry in the population policy arena POP MKT DST WIN VTC Primary interests Issues re population Chosen policy actions Beliefs Subjects not included \

13. Population-and-Environment: a sensitive, taboo subject. Many people now feel it is inappropriate to say that slowing population growth will make it more possible to preserve the environment (including ecosystems, species, water) for future generations.

14. Population-and-Environment: a sensitive, taboo subject. Many people now feel it is inappropriate to say that slowing population growth will make it more possible to preserve the environment (including ecosystems, species, water) for future generations.

15. Population-and-Environment: a sensitive, taboo subject. Many people now feel it is inappropriate to say that slowing population growth will make it more possible to preserve the environment (including ecosystems, species, water) for future generations. Decision in UN at Cairo Prepcom IV, 1994

16. Population-and-Environment: a sensitive, taboo subject. Many people now feel it is inappropriate to say that slowing population growth will make it more possible to preserve the environment (including ecosystems, species, water) for future generations. 1992 to 2002, Rio to Johannesburg

17. Why?An unintended legacy of Cairo Cairo ignored the Academies’ statement, and fostered a belief that focusing on demographic outcomes as one reason for offering family planning will lead to coercion – or may be inherently coercive. This belief assumes that family planning is asking people to do something that they do not want to do. (In reality, all over the world there is a very large unmet need for family planning.)

18. The new shift, around the Johannesburg summit

19. W P P W P P P Theories of fertility decline POP MKT DST WIN VTC Primary interests Issues re population Chosen policy actions Beliefs Subjects not included \ FP S-E S-E S-E S-E

20. New observations by the United Nations Population Division “In a number or countries we are seeing fertility decline that can’t be explained by education or economic development.” Dr. Larry Heligman, United Nations, Population Division, April 2002

21. Dr. Heligman’s examples – the S-E model has not predicted: DateTFR Ghana 1985-90 6 today 4.9 Cote d’Ivoire 1985-90 6.9 today 4.6 Bangladesh 1992 4.9 2001 3.3 Today, the average woman age 20 to 24 in Bangladesh wants 2 children.

22. The new shift goes public: “Only a few years ago, some experts argued that economic development and education for women were necessary precursors for declines in population growth. Today, village women and slum families in some of the poorest countries are beginning to prove them wrong, as fertility rates drop faster than predicted toward the replacement level.” Barbara Crossette, NY Times Aug. 20, 2002

23. The Global Science Panel’s statement for Johannesburg:Population in Sustainable Development July 2002 “Lowering fertility leads to slower population growth, allowing more time for coping with the adverse effects of that growth, and easing stress on the environment.”

24. The Global Science Panel’s statement for Johannesburg, July 2002 :Population in Sustainable Development Recommending investment in voluntary family planning and reproductive health programs: “Since research has shown that many women in high-fertility countries have more children than they actually want, these programs allow couples to have the number of children they desire, thus reducing unwanted childbearing and lowering fertility rates.

25. Bongaarts “At the Population Council, Dr. John Bongaarts … questions the assumption that when fertility declines begin they will continue to go down at the same pace, especially if good family planning services are not widely available.” Barbara Crossette, NY Times, Aug. 20, 2002

26. The Population and Sustainability Dialog Group of the Stakeholder Forum for WSSD, U.K. August 2002 Solution: “…Ensuring that women have access to information and to RHC services and modern reproductive technologies usually results in women making conscious decisions to reduce the size of their families.” The impact of opportunity on demand

27. Ms “Even in countries where poverty and illiteracy are still widespread, population is declining. But feminist health advocates have always known that women who are afforded the right to decide about the size of their families, coupled with the resources to implement this decision, usually opt for fewer children.” Ellen Sweet, Ms Magazine, summer 2002 The impact of opportunity on demand

28. Implications? • Renewed attention to the connection between population factor and environmental problems in the present and future. (Problem def.) • Broader recognition that in the population factor in the population-environment equation is amenable to change – not a “given”. • A benefits for individual = a benefits for community

29. Implications? The world summit on sustainable development, by overlooking the population factor, brought out the first broad group statements on the importance of this factor for sustainability, and on the value of family planning for both women and the environment at the same time – after years of silence. Competing schools are coming together. The Schools of Thought pattern is breaking down.

30. Spain Bulgaria Czech Rep. Italy Romania Slovenia Estonia Germany Greece Hungary Latvia Austria Belarus Bosnia and Herzegovina Lithuania Russian Federation Slovakia Ukraine Japan Portugal Croatia Netherlands Barbados Switzerland Poland Belgium Canada Cuba Sweden Trinidad and Tobago Armenia Denmark France Moldova, Rep. of Finland Luxembourg United Kingdom Singapore Korea, Rep. of Thailand China Yugoslavia Australia Georgia Norway Ireland Malta Mauritius Azerbaijan Korea, Dem. People's Rep. United States Cyprus New Zealand TFYR Macedonia Iceland Sri Lanka Guyana Kazakstan Brazil Suriname Myanmar Albania Turkey Jamaica Uruguay Chile Mongolia Tunisia Viet Nam Argentina Indonesia Lebanon Panama Fiji Israel Bahamas Mexico Bahrain Brunei Darussalam Colombia Dominican Rep. Iran Costa Rica Kuwait Peru Morocco Venezuela Bangladesh India Malaysia Ecuador Kyrgyzstan South Africa El Salvador Egypt Uzbekistan United Arab Emirates Cape Verde Turkmenistan Philippines Belize Algeria Qatar Zimbabwe Libya Syria Tajikistan Samoa Paraguay Vanuatu Honduras Botswana Bolivia Haiti Kenya Nicaragua Nepal Cambodia Papua New Guinea Sudan Swaziland Comoros Lesotho Namibia Jordan Guatemala Solomon Islands Pakistan Central African Rep. Côte d'Ivoire Gambia Ghana Nigeria Cameroon Djibouti Iraq Maldives Gabon Madagascar Zambia Guinea Bhutan Mauritania Tanzania Equatorial Guinea Senegal Eritrea Saudi Arabia Benin Guinea-Bissau Lao People's Dem. Rep. Oman Togo Sierra Leone Rwanda Chad Congo Liberia Burundi Mozambique Ethiopia Congo, Dem. Rep. Burkina Faso Mali Malawi Angola Niger Afghanistan Uganda Somalia Yemen Abortion Law I (26% world’s population) Abortion Law II (9.9% world’s population) Abortion Law III (2.6% world’s population) Abortion Law IV (20.7% world’s population) Abortion Law V (40.8% world’s population) I. Permitted only to save the Woman’s Life or Prohibited Altogether II. Physical Health III. Mental Health IV. Socioeconomic Grounds V. Without Restriction as to Reason Is Replacement Level Fertility Possible Without Access to Abortion? Martha M. Campbell, Ph.D. and Kimberly Adams, M.P.H. The Center for Entrepreneurship in International Health and Development (CEIHD, “seed”) School of Public Health, University of California, Berkeley What about the anomalies? Some countries with high fertility have liberal abortion laws, and some countries with low fertility have restrictive abortion laws. What is going on here? Zambia (TFR 5.3, law 4) Zambia has a liberal law but with a critical restriction: it requires approval by 3 ObGyn physicians. Few people are able to have legal abortions in Zambia. India (TFR 3, law 4) A liberal abortion law since 1970s, but restrictive in that only university-trained doctors can provide this service, and those doctors don’t live in most of India’s million villages, which are home to most of India’s low income people. Tajikistan (TFR 4, law 5) We don’t know about this country, or similar situations in Turkmenistan, Uzbekistan, Kyrgystan. Ireland (TFR 1.9, law 1) The law forbids abortion but safe abortion services are widely accessed across the channel in England. Republic of Korea (TFR 1.7, law 2) The law is restrictive but has been interpreted liberally for decades, to make safe abortion available. Singapore (TFR 1.7, law 3) The law permits abortions for health reasons only, but it is interpreted liberally. Mauritius (TFR 1.9, law 1) Abortion is not legal and we don’t know what is going on here. One possibility: a single illegal abortion provider could make the demographic difference in a country of only 1 million people. Myanmar (TFR 2.3, law 1) Abortion is not legal but it is no secret that it is widely practiced in this country. Many procedures are done with unsafe methods. Thailand (TFR 1.7, law 2)Abortion law is restrictive in language, but safe and low cost abortion services are widely available. Bangladesh (TFR 3, law 1) Abortion is not permitted, but menstrual regulation (vacuum aspiration in the first 8 weeks to bring on a late menstrual period) is a legal part of family planning. Bangladesh has over 10,000 providers of trained manual vacuum aspiration (MVA) services, only 50% of whom are doctors. Sri Lanka (TFR 2.1, law 1) Abortion is not formally legal but clinics provide large numbers of safe menstrual regulation services. Spain (TFR 1.1, law 3) Abortion is permitted for health reasons, but the law is interpreted liberally. Hypothesis We have observed that all countries with 2 or fewer children have widespread, realistic availability of safe abortion for poor women. (We recognize that rich women have access to safe abortion in virtually every country.) We hypothesize that all high fertility countries have constrained access to abortion, and that it is necessary to have relatively unconstrained access to back up imperfect use of family planning, to achieve low fertility. (Access to safe abortion is also critically important for reproductive health, including low maternal mortality.) This graph demonstrates the relationship between countries’ TFR and their types of abortion laws by degree of restriction, across 170 countries. Conclusions 1. What is stated in the law is less important than how the abortion providers interpret the law.  2. A country is not likely to get to replacement level fertility without access to safe abortions for low income women. Sources: The State of the World’s Children 2000, UNICEF; and the Center for Reproductive Law and Policy, 2000

31. “We must be courageous in speaking out on the issues that concern us: We must not bend under the weight of spurious arguments invoking culture or traditional values. No value worth the name supports the oppression and enslavement of women. The function of culture and tradition is to provide a framework for human well being. If they are used against us, we will reject them, and move on. We will not allow ourselves to be silenced.” Dr. Nafis Sadik, Exec. Director, UNFPA, Under-Secretary of UN, at the United Nations Conference on Women, Beijing, China, September 1995

32. The Global Science Panel’s statement for Johannesburg:Population in Sustainable Development July 2002 Signatories: Wolfgang Lutz, Mahendra Shah, IIASA, Schlossplatz 1, A-2361 Laxenburg, Austria, coordinators; and R. E. Bilsborrow, J. Bongaarts, P. DasGupta, B. Entwisle, G. Fischer, B. Garcia, D. J. Hogan, A. Jernelov, Z. Jiang, R. W. Kates, S. Lall, F. L. MacKellar, P. K. Makinwa-Adebusoye, A. J. McMichael, V. Mishra, N. Myers, N. Nakicenovic, S. Nilsson, B. C. O'Neill, X. Peng, H. B. Presser, N. Sadik, W. C. Sanderson, G. Sen, M. F. Strong, B. Torrey, D. van de Kaa, H. J. A. van Ginkel, B. Yeoh, H. Zurayk. Full address details and affiliations are available on the panel's website at www.iiasa.ac.at/gsp/