Population, Health, and Environment: Evidence-based Approaches to Policy and Programs

"It is easy to lie with statistics, but it is easier to lie without them." Quoting eminent statistician Frederick Mosteller, Population Reference Bureau (PRB) President William P. Butz opened the Wilson Center conference marking PRB's 75th anniversary. PRB seeks to keep the conversation honest by providing objective and timely information on U.S. and international population trends and their implications. Three PRB experts joined Butz to present their evidence-based approach to population policy and programs, and their unique integrated take on population, health, and environmental issues.

"For 75 years [PRB] has been positioned at the intersection of…fertility and reproductive health, population and the environment, children and families, aging, migration and urbanization, inequality and poverty, and gender and development," said Butz. "But even though the real world integrates these things, too frequently they are not integrated in the data, the research, the policies, and the programs….[i]ntelligent approaches and intelligent understanding of gender, the environment, and health depend upon understanding the linkages of those things with population."

A Gender Perspective

Reports of human-rights abuses—such as Ugandan girls forced into marriage by rebels, or Sri Lankan maids abused in wealthy countries—often do not examine the subtle yet powerful relationship between gender norms and reproductive health. International Programs Director Nancy Yinger explained that most inequities between men's and women's health are related to gender—the roles that women and men play in society and the relative power they wield. "Women face challenges in improving their health because of standard, average, ordinary gender norms that encompass them every day," said Yinger. Thus, "the differential health challenges that women and men face are rooted more in social norms than in biological differences."

Data gathered by PRB and presented in its "2005 Women of Our World" data sheet delineate positive and negative trends for women's health. For example, while girls' literacy and school enrollments are up overall, in the poorest regions—sub-Saharan Africa and South Asia—girls still lag behind boys. Similarly, childbearing begins early in these regions, even though use of modern contraception has increased across the world. "More needs to be done to give gender a more prominent place in policy dialogues around the world," advised Yinger. But policy attention is more often directed at problems that can be easily described with data and measured by indicators, and gender "is notoriously hard to measure, to disentangle the gender aspect of a problem from poverty, lack of services, poor logistics, et cetera."

The body of evidence is increasing, however. The Interagency Gender Working Group's "'So What?' Report: A Look at Whether Integrating a Gender Focus Into Programs Makes a Difference to Outcomes", produced by PRB in 2004, examines 25 reproductive health projects that incorporated a gender perspective. "Interventions to transform gender relations report positive reproductive health outcomes," stated Yinger. For example, the Population Council's Navrongo project in Northern Ghana reported a significant decline in fertility in the experimental area—16 percent lower than the control area—which it credited to the impact of outreach services and male mobilization strategies. However, as Yinger noted, "changes in gender dynamics do not come easily": domestic violence increased in the experimental area, as women and men adopted new behaviors.

Maternal mortality is a strong indicator of gender inequality, Yinger said, quoting Dr. F.T. Sai, a renowned Ghanian expert: "No country sends its soldiers to protect their country without seeing to it that they return safely, and yet mankind for centuries has been sending women to battle to renew the human resource without protecting them." As described in the "So What?" report, the Warmi Project in Bolivia tackled maternal mortality with a set of gender-sensitive interventions, such as establishing participatory problem solving and involving husbands in their programs. Their efforts paid off: from 1990-1998, maternal mortality declined from 141 to 99 deaths per 10,000 births, and neonatal mortality fell from 70 deaths to 16 per 1,000 live births.

The Global Family Planning Movement: At a Crossroads

"Remember family planning?" asked Technical Director Lori Ashford. "Family planning has been in the shadows, internationally, in recent years." According to a survey of family planning professionals conducted by Amy Tsui and Ann Blanc, the reasons for this erosion of support include the broadening of the agenda to include reproductive health, the rise of the AIDS epidemic, conservative opposition to family planning and reproductive health services in the United States, and the mistaken belief that the "overpopulation problem" has been solved.

"This is a bit like calling the game at halftime," Ashford observed. Fertility decline in developing countries is "far more complex than news reports would have you believe." Some countries encounter bumps or plateaus along the way, or even stall: "There is no guarantee that fertility decline in all countries will follow a consistent downward path and all are going to converge at two children" per woman. Despite some successes, many women's family planning needs remain unmet, especially for the poorest women in the poorest places, such as sub-Saharan African countries, Nepal, and Haiti. In addition, "women have needs in countries where fertility is low," Ashford pointed out. Only 30 percent of Romanian women, who average 1.2 children, used a modern family planning method in 1999, leading to unintended pregnancies and almost twice as many abortions as births.

Family planning offers many benefits: it can reduce abortions, prevent maternal deaths, improve children's health, empower women, and prevent HIV transmission—and it is relatively cheap. "Family planning remains one of the most cost-effective investments that governments can make," but political controversy keeps it from being a "no-brainer," concluded Ashford.

Some are trying to get it back on the agenda. The USAID initiative "Repositioning Family Planning in an Era of HIV/AIDS," for example, seeks to revive interest in family planning by reaching high-level policy audiences in sub-Saharan Africa. The upcoming Millennium +5 Summit in September offers another opportunity; although family planning and reproductive health are currently not measured by the Millennium Development Goals, Ashford said Jeffrey Sachs and the Millennium Project will recommend adding such indicators to the resolution.

Connecting the Dots: Population, Health, and Environment

Technical Director Roger-Mark De Souza drew on some 50 documented programs to show that working on population, health, and environment concerns simultaneously—-"connecting the dots"—-offers better livelihood opportunities, preserves the environment, and improves people's health. "We put population at the center of this effort," said De Souza, which looks at how population variables (gender, age, education, location, and other socioeconomic characteristics) interact with the human-made environment (structure, institutions, politics, culture, information, and technology) and relate to the natural environment.

Integrated programs, for example, use peer educators to reach young people interested in environmental issues and provide sexual and reproductive health information at the same time. And family planning policies that enable couples to avoid unwanted pregnancies reduce population pressure on environmental resources. "These projects tend to be more sustainable and cost-effective than programs that have a single-sector approach," claimed De Souza. "If you take into account the population dimensions, you get more bang for the buck, or, as we say in the Philippines, more power for the peso."

In the Philippines, Save the Children's program seeks to provide choices for couples to time their children while improving their environment by restoring the mangrove forests in coastal areas. "In these integrated project activities, family planning and reproductive health choices and information are clearly tied to community mobilization." The project has also developed integrated project indicators, such as the percentage of couples using a modern family planning method and citing the environment as a reason: "No darling, we've got to think of the mangroves," joked De Souza. The project has produced some positive results: the total contraceptive prevalence rate rose from 38 percent prior to the integrated program, to 45 percent today, and mangrove reforestation and marine protection areas are increasing.

Question and Answer

"People are aware that family planning is a good investment," responded Ashford to an audience query. "But they may think that it has already been done. There are disadvantages to being successful." Another audience member observed that some African leaders think that the population problem no longer exists because of mortality from HIVAIDS. To combat such misconceptions, USAID's Repositioning Family Planning Program seeks to find ways to make family planning resonate with policymakers, such as linking it to achieving the Millennium Development Goals and to HIV/AIDS treatment and prevention.

According to Butz, studies that couldn't show a relationship between population and economic development "depassionized" some leaders' commitment to family planning. "After all, if we can't say that countries with faster rates of population growth do worse or better in terms of…livelihoods and standard of living, there goes one of the major reasons for family planning." Butz pointed out that a country's minister of finance makes the decision to spend money on family planning, but they often lack convincing economic data. Butz called for an "objective, easily understandable number that can be tied back, on the one hand, to investments to family planning, reproductive health, and rights, and on the other hand, forward to measurable consequences for the economy….We tend to under-invest in making that kind of translation."

Drafted by Meaghan Parker.