This is the second post in a series of three where Melinda Gates and the New York Times' Nick Kristof answers your questions about maternal, newborn, and child health. Check out the first post and read all of Melinda's and Nick's answers!
Q. COSIMA BARLETT: My comments do not in any way detract from the profound admiration I have for you and your Foundation but a simple question: why do you not concentrate more of your efforts on American children who are so lacking in so many important areas as statistics now show?
A. MELINDA: When Bill and I started the foundation we decided to tackle the largest sources of inequity, both at home and abroad. Globally, the greatest disparity we saw was in health. Children in poor countries were dying of diseases like measles that were either preventable or that nobody was working to address. We felt like our resources could make a huge difference in the lives of poor families.
In the United States, although there are certainly healthcare challenges, we’ve gotten to a point where we usually aren’t talking about health in terms of child mortality. Instead, the greatest inequity we see in America is in education. Roughly 25 percent of the foundation’s resources are focused here and most of that goes towards improving our schools.
Education is supposed to be the great equalizer, but the system is failing most of our students, especially low-income and minority youth. Only one-third of students graduate high school with the skills they need to succeed in college. But getting some sort of degree after high school is critical for success in today’s economy. What we have learned over the years is that the key to improving our education system is ensuring that there is effective teaching in every classroom in America.
A. NICK: That’s an interesting question, Cosima, and it’s one I wonder about in relation to my own reporting: Do I spend so much time writing about crises abroad that I neglect problems festering at home?
I’m not sure, but there are two reasons why I understand a focus abroad. First, poverty in the world’s poorest countries really is different than poverty in America. On my first win-a-trip journey, I brought a student with me who was skeptical of all my Africa reporting. Casey Parks had grown up in Georgia and Louisiana in a poor family, without insurance, and she didn’t see that there was any need to go to Cameroon to write about global poverty. But then in Cameroon, Casey and I watched a woman named Prudence dying in childbirth, completely needlessly. And Casey told me that she realized that yes, there really is a difference – and that in the world’s poorest countries a $10 investment in a bed net really can save a life, in a way that is not true in the U.S.
The second point I would make is to push back at the idea that we should solve our own problems first, before we try to solve Congo’s or Bangladesh’s. At some point we are all humans, connected by a web of humanity, and that’s true whether we are New Yorkers and Californians – or whether we are Alabamans and Bangladeshis. It doesn’t feel right to me to ignore people’s needs and lives because they didn’t win the lottery of birth and end up with American citizenship. What matters most is their humanity, not their passport.
That said, I sometimes worry that American university students think that it’s cool and glamorous to spend a summer fighting poverty in Africa, but have much less interest in mentoring disadvantaged kids across the tracks in their own cities. That troubles me, too. And as a matter of fact, I hope to do more writing this year about America’s own challenges – including education.
Q. WASSIM RAGAB: How do you overcome the corruption in Bangladesh and still run successful projects?
A. MELINDA: It’s unfortunate and true that Bangladesh is perceived to be one of the world’s most corrupt countries. The Bangladeshis I have met have told me that they feel this in small ways on a fairly regular basis. Because the problem is systemic, it’s hard for them to go against the tide. One doctor I met with yesterday told me that nobody pays attention to traffic lights since you can buy your way out of a ticket for a small fee and because if you don’t run the red light, “everyone else will and you’ll never get to your destination.” Obviously, these unnecessary surcharges on everyday life and other forms of corruption are a major impediment to faster economic growth and it’s something the government and others must address.
The global health community has gotten quite good at figuring out ways to ensure that dollars are going toward intended purposes. Organizations like the Global Alliance for Vaccines and Immunizations (GAVI Alliance), which is the world’s largest funder of vaccines in poor countries, regularly assesses recipient countries’ finances and conducts independent audits. Our foundation also insists upon tight financial controls in our own grantmaking. Donors do more than just provide funding. By exacting high standards and requiring audits and transparency, we can also help to change the norms about what is acceptable.
BRAC/A BRAC health worker and community health volunteer provide prenatal care in the home of a Bangladeshi woman near Dhaka.
It’s also important to recognize that Bangladesh, a democratic country that has held a number of free and fair elections, is uniquely fueled by a powerful civil society. Bangladeshi NGOs have massive reach: the largest one, BRAC, reaches 110 million people! Many of the foundation’s projects are carried out in partnership with these NGOs. And the NGO’s emphasis on community-led development—BRAC pioneered the community health worker model, for example—means that more people are empowered and don’t wait around for the powers that be to solve their problems.
A. NICK: Bangladesh has a problem with corruption, and its prime minister, Sheikh Hasina, has also gone on a vengeful warpath against Grameen Bank and its founder, Muhammad Yunus. It’s really sad to see a woman become a prime minister and then use her power to attack a man like Yunus who won the Nobel Peace Prize for his wonderful work on behalf of the world’s women.
But corruption and abuse of power are a part of life in much of the world. Business executives learn to navigate around it, and so do aid workers. Sure, some gets siphoned off, but there are ways to ensure that the great majority is properly used. There are also some innovations that increase transparency and reduce corruption, such as publishing accounts so that everybody knows how much money is going to a particular rural school. And if that school never actually was built, because the money was stolen, then local people will know enough to protest. Likewise, national ID cards (as are being introduced in India) reduce corruption. So does direct deposit of sums into recipient savings accounts rather than allowing money to be funneled through middlemen. Corruption is still a problem, but we’re getting better at dealing with it, I think.
Q. SARAH KACEVICH: What is access to birth control like in Bangladesh? In that country’s context, how do you feel about the idea that improved access to birth control can reduce poverty via smaller family sizes & “older” mothers?
A. MELINDA: Bangladesh has made huge improvements in getting women access to contraceptives since its independence 40 years ago. The program has consistently maintained strong support from the highest levels of government and society, and has had great success tapping into the tremendous amount of latent demand for contraceptives. Nearly half of Bangladeshi women use modern contraceptives today, up from just five percent in 1975. The average number of births per woman has dropped correspondingly, from 6.3 to 2.3 over the same period.
We often talk about all the benefits that stem from getting women access to family planning tools, but Bangladesh went to great lengths to prove this hypothesis. In 1977, they set up a study in a religiously conservative area called Matlab, where they selected villages as similar as possible and then introduced modern family planning services in some but not in others. They tracked these 149 villages and 180,000 people for about 20 years. The results were astounding : women in the villages with access to modern contraceptives had, on average, 1.5 fewer children. They had lower risk of pregnancy-related death and disability. They weighed more, were better educated, earned significantly more money, and lived in nicer houses. Not to mention their children, who also weighed more and went to school longer.
The next challenge for Bangladesh will be better meeting the needs of those families who indicate they do not want to have any more children. Currently, their options are mostly limited to short-acting contraceptives, like pills and condoms, which require more effort and persistence to use than longer-acting methods like implants and injectables.
At several points this week, I asked women how many children they had at home. I didn’t hear many say that they had large families. In fact, the most I heard any woman say was that she had three children. Perhaps even more surprising, nearly all the women had waited three years in between children before having another. Bangladesh is unique when it comes to birth spacing—80 percent of non-first births happen at least twenty-four months after the preceding child is born. Bangladeshi women don’t just have access to family planning, they have consistent access. All of this is opening up real opportunities for these women and their families. Every single woman I talked to mentioned that her husband had a job and a good percentage of those women had jobs too, mostly embroidering or tailoring. It reinforced to me that access to family planning can have a revolutionary impact not only on a woman’s potential but also on that of her family. This kind of access could pull entire societies out of poverty.
A. NICK: Contraception has been neglected for a generation. Partly that’s because the population control effort was tarnished by overzealous and coercive campaigns in China and India, and partly because the whole field of reproductive health was made radioactive by the abortion debates. But access to family planning for women who want it is critical to moving forward in development. And it mystifies me that conservatives are often wary of it, because the best way to reduce abortions in the developing world is to promote family planning.
That said, I think Americans sometimes have a naïve view about how easy it is. Family planning, like everything in development, is harder than it looks. I once interviewed a 30 year-old woman in Haiti who was intelligent, lived around the corner from a clinic that provided family planning, only wanted two children – and yet was pregnant with her 10th child. Family planning requires health care providers and counseling, it requires steady supplies (no point in having the Pill in stock only every other month), and it requires consensus in the community. From Mauritania to Congo Republic, I’ve visited clinics that would only give a woman contraceptives if her husband accompanied her to signify his agreement.
There’s also some evidence that the most effective form of family planning isn’t IUD’s or the Pill, but girls’ education: when girls are educated, they end up having significantly fewer children. So we need an approach that includes educating girls, teaching communities (men included) about contraception, providing steady supplies in a comprehensive program that includes counseling, and research on new methods that don’t require health workers. The Population Council, for example, is developing a vaginal ring that does not require a doctor and that seems highly reliable and cheap. Bangladesh is a good example of the progress that is possible when a family planning policy is done right.