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Family Planning And U.S. Foreign Policy: Ensuring U.S. Leadership

Panelists: Ellen Chesler, Senior Fellow, Roosevelt Institute, Vivian Lowery Derryck, President And CEO, The Bridges Institute, Elizabeth Leahy Madsen, Senior Research Associate, Population Action International, William L. Nash, Major General, U.S. Army (Retired), and George E. Rupp, President, International Rescue Committee
Presider: Isobel Coleman, Senior Fellow And Director, Women And Foreign Policy Program, Council On Foreign Relations
April 28, 2011
Council on Foreign Relations

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This session is part of the Family Planning and U.S. Foreign Policy Project.

ISOBEL COLEMAN:  Good afternoon.  Good afternoon, everyone.  I'm Isobel Coleman.  I'm a senior fellow here at the Council on the Foreign Relations, where I direct the Civil Society, Markets, and Democracy Initiative; and also for many years have directed the Women in Foreign Policy Program.  And this report, "Family Planning and U.S.  Foreign Policy," is a report sponsored by the Women in Foreign Policy Program that my colleague, Gayle Lemmon -- who is actually not here today; and she's on maternity leave, appropriately -- and I have co- authored this report.  

MR.: Was that a failure of family planning?  

COLEMAN:  No, it was -- I think it was a success of family planning.  (Soft laughter.)  And also, I'd like to just give a shout- out to Andrea Flynn, who is a masters student at Columbia, who was enormously helpful and instrumental in writing this report, too.  So thank you, Andrea, for being here today.  

This report came about last year when the U.N. Foundation approached me to think about writing something and looking in depth at this issue of family planning.  And Maureen Greenwood-Basken is here from the U.N. foundation.  So is Tamara -- right here -- Kreinin.  And so our thanks to the U.N. Foundation for making this possible.  

But they came to me about -- oh, I don't know, about nine months ago, and we started talking about doing this project.  And I admit, I was reluctant to take this on.  It's not my area of expertise.  And there are many people in this room right now who know a lot more about this topic than I do.  So I throw that out there, and I acknowledge you.  There are many demography experts who are here and women's- health -- reproductive-health experts in this room.  

And what we thought and discussed was the point of this project was not to try to break new ground necessarily on family planning. And this report, for those of you who are deeply engaged on these issues, you will see, does not break new ground in that respect, it does not unearth some new research.  We have not done any new primary research.  But what we have done is pulled together a lot of the existing research.  

And the -- we launched this report yesterday in Washington.  And somebody in the audience said:  the real value of what you've done is that it's the Council on Foreign Relations looking at this set of issues.  And I do think that that is -- bottom line, that is true.  

This is a highly contentious issue.  And actually having worked on it now and immersed myself in it, I'm confused on why it is so contentious, because there are so many compelling reasons to invest in family planning.  And it is -- it lines up with so many U.S. foreign policy objectives that in many ways, it should be much less contentious than it is.  Although, we all know why it is contentious. We do know why it is contentious.  It's a reflection of domestic politics over some very contentious issues.  

But we have a terrific group of panelists here who are going to talk about the report.  The process that we went through is we pulled together a study group to look at these issues, and we purposely did not put many of the obvious experts who have worked from an advocacy  position on these issues for a long time in the room because we wanted to bring some new voices and some new perspectives to the table on this.  

And the people who are on this panel -- Liz Madsen, who is with Population Action International; she actually did one of our background papers.  We commissioned several background papers.  Liz did one looking at the connections between family planning and demography and security.  Koki Agarwal, who is with Jhpiego, Johns Hopkins, did a paper looking at the connections between family planning and global health.  Joy Phumaphi did a paper looking at the connections between family planning and economic development.  And one more paper -- Geoff Dabelko did a paper -- thank you, Liz -- looking at the connections between family planning and environmental sustainability.  All of those background papers are available online at CFR.org.  

And you can find it -- there's a page on the website that describes the whole project and has those background papers available, though we didn't publish them as part of the report.  But we did rely on those papers in the writing of the report.    

We then had a study group that met a number of times over the past seven, eight months.  Vivian is a member of the study group -- Ellen Chesler, George Rupp, General Nash, Diana Taylor, who's here in the room, and Maureen was also a part of the study group, and others. And you can get a list of the full study group members also on the website.  

But it was an interesting process of looking at all of these different perspectives and angles on this topic and then pulling it together in this document and trying to -- it was a bipartisan study group trying to accommodate, you know, a range of perspectives in this report.  

And you know, we really were not gearing this report for the experts who are deeply engaged in these topics but for a more general foreign policy audience who may be vaguely aware of family planning but not necessarily understand the data and the research behind it and even understand what it is.    

And when we were preparing to publish the paper, as I was going through the internal review process here at CFR, I was asked:  So wait.  Is family planning abortion?  And I said:  No, it is not abortion.  And I realized that if the senior folks here at CFR don't understand that point, then, you know, this is a topic that needs -- that needs more balanced conversation.  

And I'm not going to go into everybody's background here, but let me just quickly tell you who we have as panelists today.    

Vivian Lowery Derryck spent many years at USAID but runs today an organization -- let me get the exact name -- president and CEO of the Bridges Institute, which works to strengthen African governance and leadership by forging trade and development links.  

Ellen Chesler is with -- a senior fellow with the Roosevelt Institute and, as many of you in this room know, has spent many, many years working on these issues and has written extensively about women's reproductive health and family planning issues.  

George Rupp --  

GEORGE RUPP:  Has a Ph.D. from Columbia.  

COLEMAN:  And George Rupp, the former president of Columbia --  

RUPP:  (Laughs.)  

COLEMAN:  -- is also the CEO and executive director of the IRC and brings a particular perspective on the importance of family planning in post-conflict situations and for internally displaced people and refugees.  

Major General William Nash spent 34 years in the U.S. Army and has a broad set of experiences, from Bosnia to Desert Storm in Iraq, and has in more recent years been a colleague of mine here at CFR and teaching at places like Harvard and Princeton.  

And Liz Madsen, as I mentioned in the beginning, is with PAI.  

So without further ado, I'm going to just jump in and ask, Ellen, maybe if you could just start out describing -- to answer that question from the senior folks here at CFR who said, so is family planning abortion, what is family planning?  Why do we use the term "family planning" and not -- as someone in the launch meeting in Washington said, why don't we just call it "birth control," which is what it is, and maybe just a little bit on why this is such a contentious issue today.  

ELLEN CHESLER:  So thank you.  It's a pleasure to be here and particularly (I feel humbled ?) to be here in the presences of many of my longtime colleagues, iconic -- (off mic).  So thank you all for being here.   

The irony of the term "family planning" is that it was invented by Margaret Sanger in 1933, (politically as sensitive ?) but with -- (off mic) -- in the Democratic Party.  In a two-party system, we have always to confront the incredible difference that a small base of people in a party can have on the decisions that are made about policy.  

And when Sanger was trying to get birth control legalized in the United States in the 1930s, the New Deal coalition that her very close friend Eleanor Roosevelt -- (off mic) -- Franklin Roosevelt brought to Washington (were captive to urban ?) Catholics and (pleas ?) from (fundamental ?) Protestants (in his staff ?) who opposed birth control.  And she tried very hard to -- (audio break).  

COLEMAN:  (Audio break) -- we have just been through a bruising budget battle in Washington.  There were calls to eliminate international support for family planning, international assistance on family planning.  That did not in effect happen.  Although family planning assistance was cut, it was not drastically cut, as was on the table.    

But part of our conversation yesterday -- one of our panelists was Mark Dybul, who also has been part of our study group, who said that, you know, the budget that we just went through will be a sandbox compared to upcoming budget battles, both because of financial pressures but also because of the politics of this issue.  It's not over by any means.  

And Vivian, maybe I just turn to you and ask you to comment.  How is this viewed -- you know, you do a lot of work in Africa.  How is this viewed in Africa?  You know, if you look at the top 50 countries in terms of fertility in the world, all but three are in sub-Saharan Africa.  And you know, this is -- the fertility issues -- you know, where there is the largest unmet need and unmet demand for family planning, it is largely sub-Saharan Africa and parts of the Middle East and South Asia where you see the greatest numbers.  What is the view from Africa?  How is this issue talked about in countries in Africa?    

VIVIAN LOWERY DERRYCK:  Thank you, Isobel.  And first of all, I want to thank you for shepherding us through this -- these contentious waters and this entire project.  So you're to be commended for that.  

I think you have to look at Africa by differentiating between and among countries and their various levels of development.  For some of the countries that are doing quite well, such as Ghana, Botswana, South Africa, then there's a much more sophisticated view of family planning and the importance that spacing of children and reducing the number of children can have for the long-term growth of the country.  

In countries that are really post-conflict, they are -- if you are in an IDP camp, of course, then you're quite concerned about family planning.    

But if you are one of those persons that's trying to rebuild your life, women don't really talk about family planning an awful lot.  I think that they are really trying to reestablish relationships within family.  In many places, in post-conflict situations, women are concerned about political participation as opposed also to thinking a lot about this.  But as countries become more sophisticated, then certainly they see the relationship between their own fertility and their children.  

Very interesting:  There's this -- the African Union meets annually, twice a year actually.  And it has to report on what it has done to improve the status of women.  This past August, there was a major discussion on abortion, which was a -- groundbreaking

for this group of senior African women to have this kind of conversation. And they made this -- the major link between, of course, family planning, development, political participation, democracy and governance.    

So I think that African women in particular see the need.  But it -- unless your country is really driving, then it's not the most important issue -- important, but not the primary issue.  

COLEMAN:  The -- one of the things that amazed me in writing this report was looking at some of the numbers.  And, you know, there is the staggering number of how many abortions do occur in developing countries, and the number we use in the report is 35 million on an annual basis, and the role that family planning can play in reducing that number.  And there are studies show -- that show that it can reduce that number by up to 70 percent, and also reduce maternal mortality by 30 percent, both of which are goals of many people within, you know, the development community in the United States.  

I just want to pick up on your comments about women in post- conflict situations, not -- you know, family planning isn't so high on their list; they're thinking about other things -- and maybe ask George to comment on that, because he works -- the IRC works in so many post-conflict situations around the world -- where does family planning fall in the list of priorities and how it's thought about, both by the international community and by the people who are in -- you know, who are displaced and who are refugees or who are living through post-conflict situations.  

RUPP:  I think it's actually quite prominent in our programming in the very setting where we are.  And to simplify, we are  in emergency response situations where we go into either a natural disaster area or a conflict, what you also work in the immediate aftermath of a conflict or a natural disaster, and then we work in post-conflict development situations.  And in each of those, family planning, in particular contraception, are a very important part of what we do.    

In an acute emergency, it's a very bad time to have babies, and that's true whether people wind up in displaced persons camps or in refugee camps or just are moving from place to place to try to escape violence or other catastrophe.  And so when we send in an emergency response team, it always includes medical professionals.  And one of their highest priorities is to try to make sure that access to contraception is assured.  Obviously those are also situations in which rape is always a danger and so there's the more reason to make sure that contraception is available.  

In the immediate aftermath of conflict, we also are very much concerned with contraception.  But I guess our concern here is more preventative.  If you look at our report on page 19 so that all of you can get it out and meditate on it, there's really a very stunning graphic about the way in which conflict relates to age structure.  And I think it's fair to say if there were a more balanced age distribution -- which family planning could bring -- the dangers of the kind of conflict that we wind up having then to intervene in would be much reduced.  

Because the fact is that those situations in which there are a large number -- I mean, a preponderance in the population of single, young males are most likely to wind up in the conflict situations that we then have to intervene in.  

And finally, in post-conflict situations -- well, to put it maybe over-simply, but I'm allowed to be over-simple because I'm a new voice and I'm not an authority in these areas -- (laughter) -- and I've been asked to come here just as window dressing so that the people who don't normally read about family planning will read about it, but it -- so I will be very over-simple.  But in our experience in post- conflict development, it's -- it makes sense to go with the women.  

I was just in Burundi a couple of weeks ago, and one of the programs we have there are what we call village savings and loans associations.  And if you're going to invest a little bit of money so that people can begin to develop the capacity to support themselves, our experience is that it's far better to go with women than with men. Their earnings are likely to be invested in school fees rather than in alcohol.  I can use these terrible stereotypes in the way that the women on the panel probably couldn't use.  

And there's no question that women can be more effective, not only in nurturing their families, but also in nurturing healthy communities, if they have access to family planning than if they don't; because if they don't have access to family planning, they will wind up having really very hard times doing anything except raising the long series of children that they will be bearing.  

So in each of these situations -- I mean, in terms of preventing conflict, in terms of intervening in conflict situations, and in terms of post-conflict development -- family planning is a remarkably central part of what needs to be attended to.  And by that, I don't disagree with Vivian that if you just do a poll, many women will find it of higher priority to be able to feed their children than to have birth control; but the fact is those are connected, and the odds are there'll be a better chance of feeding children if birth control is also available.  And so it's just part of the regular suite of programs that we offer in all of our activities.  

DERRYCK:  And but may I just --?  

COLEMAN:  Yes.  

DERRYCK:  I really do want to agree with George.  And it is important, but it's a matter of the prioritization and where you hit women.  But in every situation, if asked, then women certainly absolutely want, desire, and if prodded a little bit will even request family planning -- in all of the three situations that you mentioned.  

COLEMAN:  Since you're talking about conflict prevention, may be we can turn to Liz.  I think it's -- I think that chart that George is showing came from your background paper.  And you've done, and PAI has done, some very interesting work looking at the connection between age structure and conflict in society.  Maybe you can just take us through a little bit of the data on that.  

ELIZABETH LEAHY MADSEN:  The work that PAI and many others have done shows that countries with very young and youthful age structures, those in which a large proportion of the population is concentrated among young people, have historically been the most prone to outbreaks of civil conflict, internal conflict.  PAI's research, the graph that George mentioned, shows that about 80 percent of new outbreaks of civil conflict that occurred from 1970 to the present occurred in countries in which at least 60 percent of the population was younger than the age of 30.  And that finding has been corroborated by some very robust statistical analysis from other researchers that controlled for the level of economic development and other indicators and found that the same relationship holds.  

Now, Isobel opened this by talking about how we are working in a sometimes controversial field, so it's very important then when we're -- that when we're talking about the relationship between demography and security, we emphasize that this is not a simplistic cause-and- effect relationship, but it's one that exists, one that's important, and one that is really grounded, we believe, in the opportunities that are available to young people in populations with this type of age structure.  

So young people are the best embodiment of a country's potential and its future development, but in many countries the government either lacks the capacity or the will to invest sufficiently in their futures.  And unfortunately, that can sometimes lead to a sense of disenfranchisement or desperation or hopelessness that can create both a motive and also reduce the so-called opportunity cost of joining an uprising or a conflict.  

So the takeaway message for this is really that it's the individual choices that are available or the lack thereof that's aggregated across a population -- are the connection between demography and security.  

COLEMAN:  Bill, you've been working in the security field for decades.  Is family planning ever thought about, talked about in the halls of the military and security establishment, or is it sort of too off topic?  Is it too much of a soft issue to -- tell us how you think about it as a military person, but also put on your -- you know, your hat as a person who works in, you know, conflict prevention and peace studies now.  

MAJOR GENERAL WILLIAM L. NASH:  At the end of Desert Storm in March of 1991, I was a brigade commander and I ended up in the southern part of Iraq, and we stayed there for a couple of months.  I like to tell my friends still on active duty I occupied Iraq before it was cool to do so.  But we were there and we had a lot of refugees that we were dealing with that were coming in, and it was largely the Shia that were fleeing Saddam Hussein at the time.  

And I had a battalion that set up a refugee camp, and they very wisely decided to put their aid station inside the refugee camp.  And quite by accident, they had a female doctor, who was a gynecologist, in the refugee camp.  Now, we're not --  

COLEMAN:  An Iraqi?  An Iraqi?  No, no -- (off mic) --  

NASH:  No, an American, an American doctor who was attached to this combat brigade.  Now, how we got a female gynecologist in the 1st Brigade of 3rd Armored Division I cannot explain to you even today, but we won't discuss that right now.  She could have been elected -- within 24 to 36 hours, she could have been elected the all- star of southern Iraq.  

You talk about whether people want this service or not.  They flooded to us.  I mean -- and this poor -- (laughs) -- I mean, I was -- I was moving people to try to get her some help and everything, but it was just -- it was a shocking thing to see the people line up to be seen, the women to line up to be seen by somebody they had confidence in and (feel good ?).

So here I am, an old grumpy armor guy, and I'm watching -- you know, tank commander guy watching that and says, gee, this is kind of interesting.  

And then you go along -- the Bosnia experiences, and the years go on, and you kind of deal with it.  And then I ended up at this place and started thinking about this conflict prevention business.  And you -- and you look at the issues of poverty, the issues of health and the issues of education that confront the world and the -- and the global scene and you see that all of those conditions, families are center to dealing with issues of poverty, health and education; and family planning is an essential element of all of that and it has great impact.  

You know, George talked and Elizabeth talked about that chart. Well, the only thing worse than that chart, if those people are both unemployed and have no opportunity for -- or ability to improve themselves.  And this is not a women's issue.  This is not a birth control issue.  This is a national security, international security issue that we've got to deal with over time.  

I can't tell you what they're thinking about in the bowels of the Pentagon or at the highest levels of our government.  God knows what they're thinking at the highest levels of our government.  But I would say to you that thoughtful people have come to realize that the United States has got to stand more -- stand for more than guns and the imposition of force and that we've got to -- we've got to deal with these issues in the world to a much greater degree than we have before.    

And I think the QDDR and the other aspects of our government machinery are coming to the point that there are concerns and there -- and there is a realization that over time we have got to be a leader in this.  

And that's why I congratulate you, frankly, Isobel, on framing this in such a way -- framing the arguments in such a way that the good old foreign policy establishment can deal with this issue.  And I'm sorry to hear that you had to educate the -- (chuckles)-- the folks -- (the embodiment ?) of foreign relations.  But it's good that we're making headway.  

COLEMAN:  Well, there is a lot of expertise in this room. And I'm not going to go through the data in the report.  Many of you know that data or know a lot more than that data.  But I think the thing to do is just open it up to your questions to any of the panelists, and we'll go in any of the directions that you would like to take this in.  

Diana.  If you could just state your name and affiliation.  

Q:  Diana Taylor.  Is there anything that did not end up in this report that you wish was there?  

COLEMAN:  We were -- Ellen and I were just talking about some of the earlier versions and what didn't end up in the report.  There was some research that we had done on new technologies and how new technologies are enabling both the effectiveness and the distribution of contraception to be much better than it has been in the past.  And that did not end up in the report.  I think to have included more of that would have been interesting, because there were some very surprising things, to me, about some of that data.    

Very high percentages of women who use contraception use what I would think of as quite modern contraception in places like sub- Saharan Africa and South Asia, but there was -- you know, some of the technologies are new and there was some controversy around some of the numbers.  There was some controversy around how those technologies are being distributed.  And we also got push-back just on the length of the report, so we took some of those sections out.  

You know, there was a lot of -- there was a lot of back and forth on language and on messaging.  And, you know, that took up a lot of time in the last several months.  But it doesn't actually change the content of what was in the report.  

I don't know, do any of you feel -- anything?  Do you want to --  

MS.     :  Maybe on this particular point about the new contraception, I was intrigued by the fact that some of the new  contraceptions offer skills and job opportunities, because in the original draft that we -- there was conversation about -- discussion about the fact that women could become providers of this new contraception, and so that would give them some income, as well.  And I thought that that was something that it would have been nice to emphasize.  

(Audio break.)  

Q:  Thank you very much.  And thank you so much for putting on this very interesting discussion.  

And it's a pleasure to see Ellen Chesler again.  She and I served together on the delegation to the CSW.  I'm Laurie Phipps.  I'm a member of the U.S. delegation to the U.N.  I work with Ambassador Rice.    

And very good that you're coming up with this sort of a report: Things are becoming more contentious at the U.N. around the issues of family planning and reproductive health.  There are countries and delegations which are trying to frame everything to do with family planning in the context of abortion which, as we started out hearing from the panelists, is not at all what family planning actually is.  

The U.S. government with the -- with the Obama administration has put health care, and particularly maternal and child health, very much at the forefront of foreign policy.    

With the QDDR, development has become the real pillar of U.S. foreign policy, along with diplomacy and defense.  And health is one of the major components of the development policy, especially maternal and child health, in a more integrated rather than vertical way, as we had during the Bush administration.  

And in fact, at the moment, USAID has 24 countries that are considered priority countries for providing family-planning services. Most of them are in Africa.  A few of them are in South Asia.  A few -- one is Haiti, one is Yemen, but it's really concentrated in Africa. And the U.S. ambassadors in these countries are in touch with very high levels of their host governments to try to make sure that they're on the same page and going in the same direction with family planning.  

And one of the things that struck me is that some of the very poorest countries have the highest rates of fertility, almost seven children per family in places like Niger; and very, very low economic development.  

And so the highest levels of their governments are interested in pursuing better access to family planning in order to reap the financial benefits of not having such a large impoverished population to have to provide services for.  And I wonder to what extent your report gets into those sort of economic benefits of providing more family planning.  I couldn't agree with the security sorts of benefits in post conflict, but I wonder whether that economic benefit is also covered.  

Thank you.  

COLEMAN:  So one of the background papers that we did looked specifically at that question.  And, you know, there has long been the sort of accepted wisdom that rapid population growth drives economic growth.  And in fact, we note in the report that the, you know, East Asian miracle, did benefit from having -- those countries had large young populations.  And young people can be sources of innovation and economic dynamism.  

But as you point out, today, many of the most rapidly growing countries from a population perspective are the poorest countries in the world that are least suited and least enabled to harness the potential of their young people.  And the interesting thing in writing this report is getting into, again, another area of controversy, is on demographics.  And I know we have some real demographic experts in  this room, but there is now a growing perspective, even in foreign policy circles, that the issue is no longer rapid population growth; it's population decline.  And you have -- you have population stability in many developed countries and/or population decline in many developed countries.  And even developing countries are rapidly aging.  And, you know, look at a country like China, which today is rapidly aging.  

And so you have people writing now about the concern from an economic perspective of declining populations and putting -- really shining the spotlight on that.  And I think that while there are some very real issues around that, in particular in certain parts of the world about rapid aging and even declining populations, that has very real economic consequences.  

The fact is that, you know, the poorest countries are the ones with the -- with the highest growth.  And if you look at Africa as a continent, it has had very robust economic growth relative to previous periods of its history in the last 10 years.  But it has also experienced rising levels of poverty in parts of Africa.  And, you know, that is directly related to the fact that population growth has outstripped economic growth.  

And so I think that there is a more nuanced understanding today in a lot of these countries that while young populations -- and as you move through the demographic transition, of course, that has enormous -- you know, it's a demographic gift or benefit to that.  When you get stuck in, you know, very, very young populations that you cannot educate and feed -- you know, a lot of the problem today if you look -- we quote in the report, the population of food-insecure people in the world will actually decline in coming years but will increase in Africa; and so -- and from total numbers.  

So you have, you know, real imbalances, and that's one of the things that we've really tried to focus on in this report.  

Yeah?  

Q:  So the U.S. government for several decades has sponsored research called the RAPID model, which looks at the impacts of continued population growth or, on the contrary, meeting unmet need for family planning in different countries, and how that would affect their other sectors.  So it looks at the employment market, it looks at food issues, it looks at education.    

And it's my understanding that -- in some settings, that research has been tremendously powerful in motivating or helping convince government leaders in certain countries to support family planning. One example is Rwanda.  I believe that the research for Rwanda showed that at continued high levels of fertility, around six children per woman, the amount of food -- of food crop that would be required would triple by about 2030.  And Rwanda's government has, as many of you know, in recent years become very, very committed to family planning and achieved some strong successes.  

Similar research in neighboring Uganda has shown that the number of new jobs that the economy would need to produce each year would grow from about 500,000 today to 1 1/2 million per year by the late 2030s.  And in 2009, Uganda's economy was only able to produce 100,000 new jobs.  So unfortunately, in that particular setting, the leadership has maintained a more pronatalist approach.    

But we have seen many examples where these connections of the benefits of meeting unmet need for family planning are founded in health and in fulfilling human rights.  They do have benefits in other sectors as well, and that can be a powerful case to make.    

Q:  Thanks, Isobel, and thanks to the panelists and the authors.  

I wanted to come back to Ellen's comment and that interesting little background on -- around the terminology, and see if we could have a little bit more thought and discussion around the terminology issue, because I think it is fascinating, particularly from a political perspective.    

You know, we have the term "family planning," and I'll come back to that.  We started out, as she explained to us, with the term "birth  control."  In the 1980s, UNICEF coined the term "birth spacing," because of its particular focus on children's health and the benefits of contraception and of spacing pregnancies.  You know, the problem with the birth spacing terminology, of course, is that it doesn't address women who want to delay a first birth or women who want to -- no longer want to bear children.  And then, of course, there's the term "contraception" and "contraceptive services," and then there's the term "reproductive health" and "reproductive rights," which has been used as -- in -- developed in Cairo and Adrian (sp) can, I'm sure, give us the exact technical -- the language that is in the ICPD program of action.  

But coming back to this question of the family planning terminology, I think it is an interesting issue of the fact that the conservatives and those who oppose these issues -- the issues that we're talking about today -- have successfully framed the term "family planning" as meaning primarily if not exclusively abortion.  Of course, that isn't what it means, but I think it's also -- we shouldn't deceive ourselves that it excludes abortion either.  Family planning is services that enable women and -- individuals and couples to have the number and spacing of children that they want to have. Abortion is one method for doing that.  

In the U.S. policy context and in the U.S. political context, that is not politically a popular point to make, and it is very often left out of the discourse.  But if you look at the term "family planning" globally and how it's used, it often does include that issue of access to services to -- to a full range of services that enable women to space their pregnancies.  

So, coming back to the question part of this, I'd be interested to hear from Ellen and Isobel and anybody else if you have any thoughts on this question of what terminology is politically viable in Washington and in Capitol Hill.  I know Mark Dybul has been doing some work around this issue as well, but I'd be interested to hear you -- your thoughts about:  Is there some new term that we could come up with?  Is there a strategy that we could use to get these -- this basic concept of access to contraceptive services more politically acceptable and more within the political dialogue in Washington, and particular on Capitol Hill?  

CHESLER:  We're talking -- my answer, I think, is that to focus on terminology is to deceive ourselves.  It's a fool's errand. The issue here is that you have a very determined base of the Republican Party now -- that switched, as I said, over history from the Democrats, the Republican base -- that opposes contraception.  So whatever you call it -- and why is that the case?  I think there is an idealized view of a cohesion of families and traditional values that for this group of individuals seems to have been disrupted by modern emphasis on individual rights, women's rights, that contraception makes possible.  Competition in the economy in this country -- there are many factors playing into this.  

And again, there's also some consistency in terms of a contest of power between religious leaders and secular leaders.  I mean, in many ways, if you look at the history of contraception and of the movement, the birth control movement, in this country over the last hundred years, it's a contest for space that develops around women, particularly when they move to urban settings, and whether that space of authority will be occupied by clerics or by women doctors, women social workers, nurses and others.  

There's a lot at stake here.  And I've -- as I've always said, I mean, you know, women are the most (faithful ?).  And so I -- you know, I mean, I feel like I'm echoing Margaret Sanger, but I -- but there is some truth to that, and we're seeing it today come to the fore again.  

In terms of pure politics also it's a question of -- there's a group of women in the center of American politics -- independent women sometimes -- who are, you know, shuttlecocks in a badminton game between the parties for who's going to control power.  So the solution may also, to these issues, derive from overstepping on the -- or overreaching on the part of the Republicans to accommodate their base. They will lose that middle, and they will understand that they've made a political miscalculation.  

I mean, I would argue that the last round in the United States has been a -- you know, taking on Planned Parenthood was a political miscalculation.  The polling in this country was astonishing, and the base of support that came to the fore on behalf of Planned Parenthood was quite impressive.  Incredible numbers:  65 percent of the country willing to have the government support services for family planning. I mean, as I often say, 65 percent of this country doesn't want the government to do anything, so that was extraordinary.  And if you  control for gender or age, the numbers were really much more compelling:  80 percent of the country under the age of 45.  So, I mean, I don't think that rhetoric or terminology is the resolution.  

RUPP:  Well, I -- you know -- Ellen, you know the history of all of these discussions much better than I do, but I would like to plead that terminology really does matter a lot.  It seems to me in many ways -- and now I'm treading on thin ice here, because I'm going to turn you off -- (audio break) -- you know the history here much better than I do.  But my sort of outsider's view is that this whole set of issues was hijacked by shifting the debate from contraception to abortion.  

It was very clear in the '70s that there was a very large majority of the country, including a huge majority of Roman Catholic women, who favored contraception.  And the Catholic Church was in -- the Catholic bishops were in the position of having -- of being told by Rome that contraception was also unacceptable.  And they knew perfectly well that that dog wouldn't hunt in the United States; that is to say, that the priests who were in confessionals were -- it was very clear that Catholic women were not going to be intimidated if the issue was family planning.  

And so there was, I think, a quite deliberate attempt to shift the terminology to abortion.  And that's why the question, "Is family planning abortion?" -- that's where that really comes from, because it made it possible to shift from being a very small minority position -- namely, opposed to family planning -- to maybe not a majority, but certainly a larger plurality that was very skittish about abortion.  

And so insofar as the debate was framed as abortion rather than contraception, it just changed the politics to a great extent.  And it is the case that maybe now it's become a matter of faith in the right wing of the Republican Party that even family planning is unacceptable.  We got to that point by segueing through abortion as the issue.  

And so if that's more or less -- I mean, that's a speculative history.  I don't -- haven't read all of the documents.  But insofar as that's the case, then it matters a lot for the -- for the Planned Parenthood debate right now to reseize the family planning/contraception lingo, which does have an overwhelming support among women and even a substantial majority among men across all political affiliations, rather than acquiescing, allowing the debate to be shifted back to abortion, in which it becomes much more complicated.  (Pause.)  

(Laughter.)  

MS.     :  I've said enough.  Let somebody else --  

COLEMAN:  Beverly (sp).  

Q:  Thank you very much and thank you for the report, which is extremely interesting and very -- going to be very useful for all of us.    

Just -- I want to just say one thing about terminology while that's on the table, but then I do have a question.  I think one of the problems is that we've got ourselves into a semantic box.  Both family planning and birth control clearly involve family planning/contraception and family planning/abortion, semantically. You plan your family.  

And so when people go around saying abortion's not a method of family planning, then I always ask:  Well, what is it?  A method of brushing your teeth?  I mean, obviously it controls your birth, and it plans your family.  

And that's why, I think, in some ways, we're in the box -- semantic box.  The ideological issues are different, and the historical analysis is also interesting, because, I think, Catholic women in the U.S. don't treat abortion any differently than other women, either.  So I don't think that that could be the main reason  for the splitting among the Catholic bishops, but that -- I don't know a lot about the Catholic bishops.  

So anyway, I did notice at the beginning of this everybody's at great pains to say we're promoting family planning, not abortion.  Oh, no, no, no, not us.  We don't do abortion.  

So that's interesting, because the report and also the dialogue has suggested that people are conscious of and compassionate about the extent to which abortion is a problem for women's health and needs to be addressed in some way.    

So what I'm actually wondering about is -- from the panel, is, during your deliberations, what strategic arguments or approaches you've developed to prevent your advocacy of family planning from becoming a further means of marginalizing, stigmatizing and demonizing abortion issues.  

COLEMAN:  I mean, this report takes as a starting point, rightly or wrongly, what U.S. foreign assistance today supports in terms of family planning, which is contraception and is not abortion. And you know, I think one of the most compelling -- some of the most compelling data out of the report is how increasing access to family planning can reduce abortion.  But in terms of trying to destigmatize abortion, no, that was never something that we were trying to do in this report.  

Oh, how -- oh, how --  

Q:  Saying that -- the approach of saying we -- of course abortion's bad, dirty.  We don't do that.  We do only family planning.  

So if that's the tenor of the advocacy, you know, well --  

COLEMAN:  You know, well --  

Q:  -- then how do you prevent -- I mean, I see the --   

COLEMAN:  Yeah, but let -- OK, so I misunderstood, but the -- you know, we -- we're not -- I mean, as an author of the report, I'm not trying also to be an advocate.  You know, we don't -- at CFR, we don't do advocacy, necessarily.  

But what we're trying to do is look at the role of family planning and as it relates to global health, as it relates to a number of different other issues.    

And I think, you know, the data speaks for themselves.  So, you know, the fact is that unsafe abortion accounts for 13 percent of maternal deaths.  You know, you can -- you can read that how you want to read it, but the fact is that many of the countries where -- which have high absolute numbers of abortion, abortion is illegal and/or highly restricted.  And they also correlate with high percentages of maternal mortality and, the fact is, in high numbers of abortion.    

So how are women getting abortions in these countries?  Well, a lot of them are self-inflicted.  They're back-room, back-ally abortions.  So even though abortion is illegal in those contexts, it does happen, and it does go on.  And it is a source of maternal death and tremendous maternal injury.  

And then one of the -- the data, as I said, speaks for itself. It's also a source of under-five child mortality.  You know, the -- we quote data in the report of when a mother dies in child birth, the infant is -- has a 70 percent, you know, increased likelihood of dying also.  So that -- those are -- that's just data.  And you can look at the data any way you want.  There's no way that this will increase the stigmatization of abortion for some, because it's already beyond the moral pale.  And for others, you can -- you can look at the data and make of it what you want.  

MS.     :  Isobel, sorry.  Can I just jump in with one quick -- very quick addition or a comment on that?  I think that in terms of this point that you're talking about, I think that the distinction, both from a data perspective, as well as from a messaging perspective that needs to be made, is that it's not abortion per se that is a cause -- the cause of maternal morality:  It's unsafe abortion.  Safe abortion is, in fact, not a cause of maternal mortality.  

COLEMAN:  (Off mic) -- we -- but we mention -- we did -- (inaudible).  

MS.     :  OK.  It's -- the terminology you were using just now was just abortion.  That's fine.  

COLEMAN:   Oh, no.  Sorry.  Unsafe abortion.  

MS.     :  OK.  

COLEMAN:   Yeah.  

MR.     :  Let me jump in, if I could, just for a second.  If I changed the name of this report to "Energy and U.S. Foreign Policy: Ensuring U.S. Leadership," we'd be -- we'd be addressing the issues of energy in a -- in a generally nonpersonal manner.  But when you talk about family planning, it automatically becomes personal.  Well, the genius of this report is trying to put it -- in my view, is trying to put the issues of family planning in the poverty, the health, the education framework or the economic security and environmental framework -- however you want to kind of describe it.  And I think it's very important for us, as we advocate U.S. foreign policy approaches, to try to maintain that.    

I -- when I would get mad at Isobel during the conferences -- I'm on the board of PAI, the -- Population Action International.  And I would put my phone on mute and say, some expletive deleted, this is not a PAI board meeting.  This is not a discussion of reproductive health rights.  You know, this is a discussion of U.S. foreign policy. I didn't say it too often.  But I think -- I think what's very important about this report is that we approach it from that.    

And those of you that know so much about the issues, OK, of reproductive rights, just to name one, and all the women's health issues in the larger context of family planning, my hat's off to you and I respect that.  But we're trying to go after a different audience here.  We've had this discussion about who you're writing for.  You're writing for the foreign policy establishment.  You're not writing to the specialists in the fields of family planning and associated fields.  And so that is my comment on what was left out and also on this discussion of how you define things.  

Q:  I look forward to reading it.  Congratulations, Isobel.  

Turn the some -- the heading of this report around.  What does family planning look like from a standpoint of Chinese foreign policy, and Indian foreign policy?  Those are both big countries that have each taken quite different tacks domestically.    

And what are they doing in their foreign policy, especially with respect to Africa where both China and India are active?  

MADSEN:  Well, I can't give a very good answer.  PAI started looking into the issue of China as a donor in Africa, and so far we haven't gotten very far.  And I hope that some of the foreign policy experts around the table will correct me if you have a different understanding.  

But about Indian foreign policy, vis-a-vis family planning, I know nothing.  About China, my understanding is that Chinese foreign policy is sort of a give and take.  The Chinese take resources, and they give what the country they're investing in would like.  So -- and it's often infrastructure developments; you know, stadiums, roads, bridges.  I have not heard of concentrated Chinese investment within the health sector.  You know, I remember reviewing an agreement or a draft of an agreement between China and an African country.  And it was very much sort of what the African country proposed.  The Chinese would say, you know, here's the money, do what you would like.  

But, again, if others have a different understanding, please.  

MS.     :  Well, if I could just jump in a little bit, China, as far as I know, doesn't do very much at all on trying to export their family planning.  A country that does, though, is Brazil.  Brazil in the U.N. context has been very, very active; a very staunch proponent and supporter of reproductive health, reproductive rights, family planning; and was very, very active at the recent CPD, trying to promote better family planning, especially in the context of what they call South-South cooperation.  

India has a very, very strong women's movement and does a lot of activity on women's issues, especially scientific sorts of issues and women's rights.  But I haven't seen them being particularly vocal when it comes to family planning or abortion.  And I think it's because in their own country, there's probably a division of views.  But I see Adrienne Germain nodding and shaking her head, so she may know more about India's foreign policy.  But Brazil's a real leader.  

COLEMAN:  One of the things, I think, is important to remember is that family planning is one of the great success stories in the development world.  I mean, this is something that, you know, has had tremendous impact and success.  You know, if you look at the statistics and the data, you know, contraceptive -- contraception  usage has gone -- in 1960, I think we say it's around 10 percent in the developing world.  Today's it's, you know, close to 60 percent -- 53 (percent), 55 percent, something like that.  

And you've had countries -- we give a nod to a couple of them in the report -- Mexico, Indonesia -- which received family planning assistance from the United States and then graduated out from American assistance programs; and in effect, have become donors themselves. Brazil is a perfect case in point, that it does make family planning -- it provides assistance to some of its neighbors on family planning, and also it champions it in an international forum like the U.N.  

But, you know, there's a lot of success that's happened in family planning.  It's almost one of, you know, the great, I think, unsung development achievements, is the extent to which contraception is available in so many places around the world in a matter of, you know, decades, in comparison to other health interventions which have not had the same traction in the world.  

We had over here Adrienne -- oh, Joan (sp) first.  

Q:  I'm going to go ahead first, because -- (inaudible) -- Adrienne might say.  I'm suffering from an overwhelming attack of deja vu.  And I had to make a little calculation here.  Thirty-eight years ago, when I went to work for John D. Rockefeller's -- (inaudible) -- we would never have imagined that there would be a conversation like this in the Council on Foreign Relations.  So I really want to commend you, Isobel.  I mean, I think this is -- this is great.  I think it's a start.  I hope it's not backwards into the future.  I think there's an expediency aspect to this report which is valuable.  And I'm not -- I don't -- I'm sounding critical, but I don't mean to be.  I think it's really important.  

Let me say something about abortion.  Abortion is an organizing tool.  It's like birth certificates.  Watch it.  It doesn't really have anything to do -- it has to do with a moral fight that we have to fight on the merits.  

And there's no point in trying to hide it under language that is -- can be -- you know, somehow we can wriggle out of it by talking about different kind of ways of describing it.  

I got myself into a lot of trouble in the White House in -- I don't remember what year -- must have been coming up -- must have been early '90s -- with the then-vice president, when I told him, "Mr. Vice President, there's no hiding place from abortion.  There's no hiding place."  And that's one of the reasons why the Cairo Initiative talked about women.  It's about women's rights.  And I support Ellen, obviously, when she says that we would love to see more of that in this -- in this report.  And I can see it's just a first step, and I hope you go further with it.  

But the women -- if you talk about women and you talk about women's lives and the reality of women's lives, then you don't get caught in this -- in this other semantic discussion nearly as easily.  

So -- and just one other thing.  Women's rights is American foreign policy, particularly with the secretary of state we have now. So we can't just say, oh, well, we can't talk about women because it's not about foreign policy.  It is foreign policy.  Thanks -- (audio break).  

COLEMAN:  (In progress following audio break.)  I can just tell you a little bit about what the roll-out strategy is.  I mean, we did a launch event, as I mentioned, in Washington yesterday; this event here; we're doing -- the report will be written up in The Chronicle, which goes out to all 4,000 CFR members; there's an expert brief that will be on the website, that's also publicized and sent around to journalists.  There was a press release that went out yesterday to journalists; you know, our vast number of journalists -- I think it's almost 20,000 journalists from around the world who get our press releases.  

On May 13th, I'm doing a session on Capitol Hill with staffers and -- you know, from both sides of the aisle.  I'm also in the process of setting up meetings with various congressmen who will take the meeting.  And, you know, again, it's not trying to preach to the converted, but it I think provides some intellectual ballast for people who want to do the right thing.  And there are those who will never engage on this issue and I can assure you we won't be meeting with them, because they won't meet with us.  

But there are others who, I think, want to do the right thing and are interested in learning more.  Did a very good session with folks from USAID yesterday.  And we're doing a session at the Aspen Institute, another big public event in Washington.  So we have a number of things.  We're doing something at the State Department.  We're trying to do a meeting at the White House on the report.  So we are trying to reach out to a range of different communities with the report.  And we're doing some spin-off writings that come out of the report, too.    

But you're absolutely right.  There are those for whom they -- you know, they just won't engage on this issue, but there are others who, I think, are looking for, you know, the credibility of the council, in some ways, to help them move along a spectrum on these issues.  

Yeah.  

Q:  On this whole question of the rollout (of ?) increased access, I was wondering if it's possible to find some overseas supporters.  For instance, we were talking about President Kagame, and he's certainly someone that has influence certainly with certain members of Congress, and there may be others that would be interested; and also, to look at the -- some of our allies, like the British and DFID and what they are now doing in increasing their investment in development and family planning.  

COLEMAN:   Yeah.  

Q:  So that might be another source of --   

COLEMAN:   Those are -- those are good ideas.  And also, I didn't mention the report has been mailed out with a cover letter from CFR President Richard Haass to 25 VIPs -- all of the major Republican presidential candidates are on that major VIP list -- and also to another 600 influential people with a cover letter from Jim Lindsay, who's director of studies.  And if anybody else wants additional copies of the report, we have additional copies that you can hand out and give to anybody that you'd like.  

And Dick (ph), you had a question?  

Q:  Are we out of time?  

COLEMAN:   No, we've got -- last question.  

Q:  OK.  This is a foreign policy question.  I want to go back to the now famous chart on page 19.  I notice, you know, this is the chart of the correlation between youth bulge and civil unrest.  It ends in 2007.  It just strikes me that the greatest current example that probably validates this chart is what's going on in the Middle East and North Africa.  And someone else mentioned that USAID has targeted, I think, 24 countries mostly in sub-Saharan Africa.  Maybe Yemen was included in that batch.  

So the question obviously is, why isn't Middle East and North Africa per se being targeted for more family planning?  And is there something about the region per se in the Arab/Islamic context that is particularly resistant to this type of thing?  

COLEMAN:   Liz, can I take that?  (Chuckles.)  

It's been fascinating from a demographic perspective to see the response to the political uprisings and revolutions over the past few months, and in North Africa in particular.  And the media coverage here, we've seen a lot of articles that claim that these are countries with high youth bulges.  We know a youth bulge is correlated with conflict.  They're reinforcing that.    

Well -- not unfortunately, but unfortunately, in my mind, it's not quite that simple.  Actually, there's a lot of diversity demographically across the Middle East and North Africa.  Tunisia, which was the spark for this, is actually one of the most advanced. In terms of age structure, it's had a successful family planning program for decades, and it's fertility rate is close to the U.S., of a replacement level, about two children per woman.  Egypt is a little bit behind that but has still made a lot of progress.  Yemen:  second youngest age structure in the world, fertility rate of six children per woman, 75 percent under 30.    

And the chart mentioned the correlation between age structure and conflict, but what it doesn't show is similar research that's been conducted on age structure and democracy.  And this, I think, is the key, that what we are seeing happening in the Middle East and North Africa is unfortunately happening in a context of conflict, because autocratic governments are resisting the will of their people.    

But what these movements are really about is the search for democracy.  And so in that sense, they're -- the way they are panning out is fitting into the demographic research.  Tunisia has had the most success so far.  It was the earliest to make this -- Egypt -- I mean, the story's not over.  Egypt has also succeeded in removing an autocratic governor -- leader.  Yemen, the story is yet to be told. But from a demographic perspective, we would expect that Tunisia would have the best chances of any of the countries in the region, and that unfortunately Yemen's chances would not be as strong.  

So as for U.S. investments, because there have been some great successes, like Tunisia, like Egypt, we've learned that religion and culture per se are not impediments to uptake of family planning.  Many of the successes in that region were, in fact, driven by support from clerics.  And many people are surprised to learn that the fastest demographic transition in history occurred in Iran.  

COLEMAN:  We are just about out of time, but I would end by quoting in our report, which I think came from you, Liz, that demography is not destiny.  And Tunisia may have the best crack at a successful democratic transition, not only because of age structure but because of a homogenous population with the highest GNP per capita in the region and many other factors that go into that, but demography is one.  And I encourage you to read Liz's paper.  There's some very interesting work on and statistics on demography.  And all of the papers, as I said, are available online.  

Thank you all for coming today and thank you for our panelists for joining us.  (Applause.)

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