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

Panelists: Mark R. Dybul, Distinguished Scholar And Co-Director Of Global Health Law Program, Georgetown University, and Koki Agarwal, Director, Maternal And Child Health Integrated Program, Jhpiego
Presider: Isobel Coleman, Senior Fellow And Director, Women And Foreign Policy Program, Council On Foreign Relations
April 27, 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:  Welcome, everybody.  I'm Isobel Coleman.  I'm a senior fellow with the Council on Foreign Relations in New York, so it's a pleasure to be here today in Washington.  And thank you all for coming to this launch event.    

I'm also the director of the council's Women and Foreign Policy Program, which is the sponsor of this report that we're talking about  today, and also the director of a new initiative at CFR, Civil Society, Markets and Democracy, which keeps me busy.  

About -- almost a year ago, maybe nine months ago, the U.N. Foundation came to us and asked CFR to consider looking at the issue of family planning in the context of U.S. foreign policy.  And I must admit I was a little reluctant at first.  It's not my area of expertise.  I know there are many people in this audience who know a lot more about this topic than I do.  But I agreed to do it because I think it's an extremely important issue.  It's a very, very difficult subject in some surprising ways.  In some ways it really shouldn't be difficult, but it is.  It's a political topic, but it is also one that is so critical to so many aspects of foreign policy and U.S. foreign policy goals that I thought it was a very worthy topic and issue to delve into.  

So we had a process of commissioning papers, some background papers, from experts.  One of our experts is Koki Agarwal, who is with -- she's a long-time expert in maternal health, reproductive health, family planning, child health.  And she runs the maternal and child health program with Jhpiego.  And she did one of the background papers for us.  We have -- (inaudible) -- four background papers, and you can find them online at CFR, that helped inform this report.  

We also then put together a study group, a bipartisan study group of people from the different aspects of the foreign policy community. And we purposely did not go after the usual suspects who work day-to- day on issues of family planning, because we wanted to bring a new perspective and new voices into the process.    

And one thing I can tell you is there are many of you in the audience who are and have been deeply engaged in issues of reproductive health and family planning for many years, and you will probably find nothing new in this report.  That was actually not our goal.  We didn't break any new ground.  We haven't uncovered any new research or statistics that you probably haven't seen if you are deep into this field.  But that never was our purpose.  Our purpose was to bring together the research that has been done and to look at it in the light of U.S. foreign policy.  

And as I said, I'm not -- I didn't start out as an expert in this topic.  I think I've become an expert in this topic over the course of many months of doing research on it.  And there are certainly things that surprised me about it.    

But on of the things that is so surprising -- and I'm going to start with Mark Dybul.  And I'm not going to go through everybody's file.  You can read them in the handout.  But as many of you know, Ambassador Mark Dybul headed up a number of initiatives for the Bush administration, including PEPFAR, and is now at Georgetown running the Global Health Law Program, which is very interesting work.  And Mark, as I said, was part of our study group.  And I'd like to start with Mark.  

And maybe you can help -- not everybody in this audience is deep into these issues -- just sort of set the context of why is family planning -- international family planning such a controversial issue. It seems like today in America there's enormous consensus around women's right to access family planning, and yet when we start thinking about it in an international context, it really becomes a hot potato.  

MARK R. DYBUL:  That's a very good question.  And first I want to thank you, Isobel, for writing this report, with Gayle, and for the work you did on it and taking this on, because I think it is very timely.  And the last -- the recent budget debate gives us a good sense of how timely it is.  

And, you know, rather than giving a historical perspective -- because everyone's viewpoint of what has happened is colored by where they sat while that history was happening, and everyone will have a different perspective based on that -- I think if we look forward to where we are today, we're at a situation where we also have a problem domestically, and it's the same problem domestically and internationally, and that's effectively the conflagration of abortion and family planning, and a perception that they are the same thing.  

Despite the fact that there are many pro-life, pro-family-planning politicians and many pro-life, pro-family-planning people, we've had a conflagration of those two issues.  And that's fundamentally -- that's fundamentally where we have a problem.  

And it really is unfortunate because family planning has -- is such an essential part of interventions for health and relate to many other aspects of global development.  

And the point of the report, to me, is that it's trying -- while not breaking any new ground, trying to restart or jumpstart a new dialogue and a new debate that is open, respectful, balanced; helps people get out of their corners, which is where we've gotten to, to have a dialogue and disagree where we need to disagree -- and there will be disagreements; there should be -- but to do it in a respectful, trustful way, and to get all the issues on the table.  

And -- but the fundamental issue is for international, as domestic, does family planning include abortion or does it not?  And on foreign policy, it's relatively easy.  There are three laws that make that clear, it is not -- you cannot use U.S. government money internationally for any -- abortion in any way, shape or form.  We have other laws domestically related to that.  

And -- but -- and I think it's largely because of a breakdown in trust and conversations and -- which is -- can happen, that we've gotten to the point where family planning is seen as including abortion.  And that's what we need to work through and talk through.  

And I think what this report really starts to focus on is focusing back on where family planning actually started a long time ago, which is giving families -- that's why we have family planning -- the decisions and ability to make a decision to have a loving, happy, healthy family; to allow mothers and their partners, husbands, to make a decision on the size a family that they can support, that they can love, that they can care for and that will contribute to their own family unity but also, therefore, to the community's unity; and that family planning gives that opportunity to individuals.  

And there are some people that don't accept family planning, and we also need to accept that.  Part of the problem is we also are -- have gotten into a sense of that person is bad because they have that point of view, or that person -- everyone has a point of view to be respected, and we need to have that open dialogue.  

And -- but I think that central issue that you start out with in this report, getting back to that central issue of happy, healthy families and giving people the tools to make those choices.  

A second part of this has been some of the global and some countries' messaging of, you know, this is the size a family should be and population control.  And that's caused a huge problem as well. And so we move from voluntary family planning where you bring it down to the level of a family making a decision to a state making a decision.  And that makes a lot of people uncomfortable.  And that happens still rarely, but unfortunately people start pointing to things that they -- that make their case as they're getting into their corner.  And that conflagration has been a bit of a problem too, moving it from the family to the state.  

So focusing it back on the family, focusing it back on giving tools to families to make the decisions to create a loving environment where they have the best opportunity, I think, is what this report does nicely.  

COLEMAN:  One of the things that surprised me in the writing of this report is the data on abortion.  There are 35 million abortions that occur annually in developing countries.  And the data shows that increasing access to family planning could reduce that number substantially, by 70 percent.  

Why is that surprising to me?  (Chuckles.)  I mean, I should have known that, but why is that not a statistic that more people understand and embrace?  

DYBUL:  I don't know, because it's a point that is made often, especially by pro-life, pro-family-planning individuals that if you -- if you are -- have difficulty with abortion, one of the single best tools is to have access to family planning because you will reduce abortions by 70 percent, and you'll reduce the complications of abortion by 70 percent.  

But it really gets to the bigger issue in a lot of ways.  And we had a conversation earlier -- someone who should have known abortion was not included in family planning had to ask you that question.  And that happens all the time now, because it has been -- there has been this association.  And rather than seeing family planning as a very effective tool to reduce abortion, we've -- it's gotten into that is abortion, and it's actually not.  

And so we've had Republican presidents, Republican administrations, Republican members, many of whom have supported family planning precisely because it reduces abortion, and then it also has other health benefits to the women, reducing maternal mortality, reducing neonatal and childhood mortality, in large part because the mothers are still alive.    

So I think it is the -- part of the whole problem.  It's not just understanding that family planning reduces abortion.  But it's not -- it's not -- it is not -- it is not.  And that's a conversation people need to have, because there's disagreement.  But we can agree on family planning, that it is not abortion, in fact reduces abortions. And that is one of the reasons we should support it.  But I think it's wrapped up in that whole bigger issue.  

COLEMAN:  Well, Koki, let me -- let me turn to you, because you're, you know, one of the great experts on this subject.  And as Mark just mentioned, family planning is of tremendous benefit to global health issues, in particular in women's health, neonatal health and under-five child mortality, as a way to reduce that.  

What are -- what are some of the ways that family planning actually does improve global health?  

KOKI AGARWAL:  Well, it's a really good question.  And I -- again, I just want to join Mark in thanking you for writing this report, because I think it highlights -- as you said, it's not new data, but it's data that we all need to be familiar with and be able to talk to to be able to make a convincing argument that family planning really does matter for improving health, not just of mothers but also the newborns and children.  

And I'd like to start by just sharing some thoughts from my work in Nigeria and Bangladesh of -- within the MCHIP program.  And before I give any statistics, I think, I just want to share that we are working -- for instance, in Nigeria, we were working in three northern states which are very rural, very Islamic and very conservative.  And yet as we went to work in those states, we recognized that the family planning prevalence -- while the maternal mortality was much higher than the national average in Nigeria, the family planning prevalence was much lower.  So it was 1 (percent) to 2 percent in those three states that we were working in.  

And as soon as we went in, the women were asking for family planning, so it was not -- it was an expressed need from the women.  They wanted to use family planning to be able to better space and have healthy timing and spacing of pregnancies.  But there was no way that they could access family planning services, because they were not working outside of the home.  They were not able to go and seek services, and the services were not there to provide them the commodities.  

So I think for me, as a public health professional, it just seems like it's a no-brainer that, you know, we have a huge group of women who have an express need for family planning services.  Of the 880 million women who want to use or prevent pregnancy, only 215 million of those women are still not able to use family planning and they have an un-met need.  And yet we are not able to make sure that we are able to provide that service -- those -- that service to those women.  

And what we found, even in the most conservative and challenging areas, we were able in three years to raise the family planning prevalence in those three states from 1 percent to 15 percent, so -- which was a huge, remarkable growth which showed that there was a latent need for family planning that women were really craving.  And if you provide them with the right environment and the right services, while working with the external environment of the men and the communities and the religious leaders, that you can actually make it happen.  

A similar situation in Bangladesh.  We went in at the community level in Silhet (ph), which is one of the most conservative and remote part of Bangladesh, where nobody wanted to introduce the word family planning.  They said we just want to talk about saving newborn lives. And as our household counselors went house to house, every time they went to the visit -- went to visit the women, either pre-pregnancy or during pregnancy or just postpartum, they said, when can we have access to family planning methods?  And again, after year two, we were able to introduce family planning, because it was demonstrated to USAID and to the ministry of health over there that these women do want to seek family planning, so now they're able to get it from the -- (inaudible).  

So I'm -- you know, I -- it's interesting to me, this whole big debate.  I mean, there's really good reasons why we should support family-planning programs from the health perspective, because it has a huge impact on saving maternal life.  There's new research that's out there that's quoted in this paper and in my paper which talks about the fact that it saves not just -- prevents the risk that a woman faces every time she gets pregnant and could die from a pregnancy- related complication.  But it -- also within each pregnancy, it prevents the higher risk because of the type of pregnancy you have. So it avoids the higher-risk pregnancies within every pregnancy.    

So both from preventing the numbers of times you're exposed to pregnancy and preventing the higher-risk pregnancies, family planning can save maternal life.  And there's estimates that you'll see from many different reports that show that almost 30 percent of maternal morality (sic) could be avoided if women were given access to family planning.  

And linked to that is the impact that it has on the child and the newborn.  It shows very clearly -- much of the research shows that 70 percent of the -- newborns where the mothers die have a 70-percent higher chance of dying, and the child mortality is also higher.  And if they -- and they've shown that -- in one of the research actually from longitudinal data in Bangladesh, they've shown that if the mother dies, there's a huge impact on the surviving child.  They have a much higher risk of dying.  If the father dies, unfortunately, there's no impact at all.  So, you know, the fact that you can save the mother through family planning, and have an impact if she spaces her children between 24 to 36 months between the pregnancy and the birth, that she can save -- that her newborn and the child will also be saved.  

And all of this data is known, has been around for a long time. I think it's just whether people who are -- who need to listen to this message are just not listening to the message.  I'm not sure what it is that our community can do more.  But as a public health professional, it just surprises me that this data is not compelling enough to somebody to make a case for family planning.  

COLEMAN:  Well, actually, I've been asked a number of times what surprised me about the data and the research.  And one thing is not only, as I already said, the huge number of abortions that occur and how family planning can dramatically reduce that but -- you know, I've worked on maternal health issues so I was well aware of the impact on improving -- reducing maternal mortality.  But the birth- spacing data is very, very interesting and compelling.  You know, women just spacing out their births, you know, as having a live birth more than 24 months after the last live birth -- or pregnancy more than 24 months after the last live birth, dramatically reduces infant mortality and maternal mortality.  So, you know, the combination of all of these things, from a -- from a health intervention, it's just incredibly compelling.  

And yet, Mark, to come back a little bit to the politics, you know, we just went through this bruising budget battle, and there was talk about dramatically decreasing family planning support.  That  didn't happen in the end.  It was reduced but not, you know, fully eliminated, as some had suggested.  Why -- how is it that people who really care about abortion, for example, and also care about mothers and children, have a blind spot when it comes to family planning?  

DYBUL:  Mm-hmm.  And I think it's also important to point out that mother dying has an impact beyond health.  The kids, especially the girls, are less likely to go to school, less likely to be fed, less likely to get medical care, so overall -- and the impact is much worse on girls than on boys in all of the categories.  So keeping the mom alive is essential.  

There's no question -- if you look at the floor debates, it's very clear, the issue comes back to abortion.  I mean, there's -- that is absolutely the case.  And the fact of the matter is, on the Republican side, the support for development in general is not exactly, you know, roaring.  There are -- fiscal conservatives don't have an easy time, especially in this environment, in our own budgetary environment, sending money abroad, unless it's for issues that they equate with immediate national security.  

The support for development among the Republican side, among conservatives, comes from social conservatives.  That's the base of the support, because the support they have -- and for many of them, it comes from their faith, that to whom much is given, much is required; that it is our responsibility as a wealthy nation, even with all of our problems, to support those who are less fortunate than us.  But they also have social conservative views on lots of other issues, and so it's a -- that nature of it actually makes this issue more difficult in many ways, because the same people who support the health programs and the maternal health programs and the development programs, education programs, are social conservatives.  

And the fact of the matter is that many of them will accept family planning -- not all, but the vast majority will.  They will not accept abortion.  And that's where we've gotten to a point where family planning has been equated with abortion.  And that's fundamentally where the problem lies.  

And many people are not aware, literally, of the data on reduction on abortion.  Many people are not aware that money cannot go from the U.S. government to abortion.    

But there's also a sense that there's this thing called fungibility of resources, that if you give resources to institutions that do abortions for family planning, that just frees up money so they can do abortions.  And -- but that's true in a lot of areas.    

And I think where we've gotten to that point is not because we have to get to that point.  We've gotten to that point because we've moved away from kind of that family-centered decision making for the health, well being of that family and in a trusting conversation and in a respectful conversation where different points of views are understood in a way that you can have these conversations.  We're -- I'm not sure we're at the point where we can actually sit down and have these conversations.  This can take a lot of work.  And I think this report helps us get along that way.  By framing it in a very balanced -- (inaudible) -- back to that family-centered nature, and being clear that there will be disagreements on abortion and whether or not abortion should be funded.    

But family planning is not abortion.  It reduces abortion.  It contributes in a significant way to health of mothers and their children and, therefore, we need to -- we need to be clear about support for that.  

And the budget situation is just going to make it more difficult, because it's going to make it more and more difficult for the advocacy for resources.  We actually did pretty well in global health compared with the rest of the budget.  But family planning took a hit while other programs did not.  And I think this current budget fight was a sandbox compared to what we're looking at in '12, '13, '14.  

COLEMAN:  One of the -- one of the interesting contextual issues, I think, that affects family planning today is the whole debate over demographics.  And in doing this report, I read a lot of different views on demographics.  And, you know, clearly there is an emerging view that the problem has long been viewed as being one of overpopulation and rapid population growth, and that is shifting to a view of no, in fact, the real problem today is too little population growth.  We have rapid aging of various countries in the world, Europe in particular, parts of East Asia; even developing countries now, some of them are experiencing some very rapid aging.  And the issue is not  too much population growth, it's too little, which, in my mind, is completely the wrong way to look at this issue.    

The reality is not -- there are countries that are experiencing rapid aging and either (then ?) population stability or decline, but there are still many countries in the world that are experiencing very, very rapid population growth.  And while population growth can be a source of economic dynamism and innovation, and youth can contribute in all sorts of positive ways, the countries today that have the highest fertility rates are also countries that are least able to harness the productive capabilities of youth.  

And Koki, when you -- when you look around the world at those, you know, high-fertility countries -- and I think you work in a number of them around the world -- what are some of the -- what are some of the insights that we can draw from their demographics?  

AGARWAL:  Well, I think that, you know, the -- some of the comparisons that you can make in terms of the countries that have experienced or have managed to reduce fertility over time -- which many of them have, even in the developing world -- have shown the kind of economic progress and the social progress within their country programs which is not seen so much in the other countries that have managed to just be stagnant in terms of their fertility rates.    

I think the interesting comparison could be, let's -- if you took -- look at Pakistan and Bangladesh.  They were -- you know, at one point they were one country.  And Bangladesh adopted a very strong family planning approach where they have managed to increase their contraceptive prevalence and their fertility rate has come down, while they're still a huge country in terms of the space they have.  But it's still -- in terms of the fertility decline, their experience is strong.  Whereas I think you make the case for Pakistan in this report of yours:  They have not had the same decline that they -- that Bangladesh has seen, and it has a major impact on the health consequences and the issues in terms of progress, economic and otherwise.    

So I think that the -- you know, if we look at the issues of demographics, there's the transition that every country will achieve, but you could change the transition and move the transition in the direction that can empower the country to be more progressive and more economically empowered than if you had to deal with huge populations that are (always draining ?).  And there will always be a mix, as you said, of the young and the old.  And countries will have to make priorities for those.  

But I think, again, the central question is, you know, if we were to be able to help countries space and time their birth so that we could meet the demand for family planning, then they would -- the countries would transition in a -- in a direction that would -- that would be concomitant with the group that they could achieve over the time period that they had.  I think if you don't have that growth alongside the -- meeting the desires of the population, it's always a problem.  

DYBUL:  If I -- if you don't mind me jumping in there, Isobel, because I think the way Koki just talked about it is important, because this has been another fault line in the debate.  

There's a perception, real or otherwise, that family planning is being promoted as THE solution to development, if we just controlled the size of populations, we wouldn't have poverty, we wouldn't conflict, we wouldn't have famine, we wouldn't -- and to people who look at that family decision making as the key thing, it starts to sound like state solutions on population control and not a family decision.  And the way you described is -- what we're doing is trying to give tools to families and individuals for unmet need for people who voluntarily want to -- want to have a smaller-sized family for their own family needs, which contributes to these other things, but it's not starting from if we just controlled the population we would have these outcomes.  

And I think you did a very good job in this report of reflecting that shift in the conversation, which is absolutely essential, both because that's the reality on the ground and that's what we're trying to do with families and because that is a fault line in the political conversation about these issues.  

And also you talk about in the report that there -- families should choose the type of approach that is best for them.  It has to be evidence based -- we can't be promoting things that don't work --  but evidence-based, natural family planning -- if it works and that's what the family chooses or other methods, but they -- everything should be available for that family to have the choice and in an evidence-based way at the family level that then contributes not we need to achieve these objectives, therefore let's do that.  

COLEMAN:  Well, I'm going to open it up to your questions in a minute, but before that just share one of my own personal anecdotes. And one of the reasons I actually wanted to do this project is from traveling in some of the same types of countries you're talking about, Koki -- very conservative, traditional, rural areas; very, very low rates of female literacy, I come across this demand for family planning.  

And some years ago, I was in Afghanistan in a rural village visiting a women's center.  And the women were being trained on economic -- for economic opportunities, skill building for economic opportunities.  And all these women wearing their burqas in this very hot, dusty room; suddenly there was a commotion in the back and one of the women there started shouting out something.  And I asked the person translating, what is she saying?  And some others jumped in, and people then started shouting things in the back.  And he said -- the translator said, oh, she's saying what good is it to have jobs training if I don't have access to birth control?  Where's our birth control?  And she was shouting from the back of the room, all these burqa-clad women.  And I thought, you know, wow -- you know, here in Afghanistan, they are aware of contraception and they want it, and they can't access it.  

And so my last question, Koki, as you mentioned in Nigeria that you actually worked with male leaders, religious leaders too, how -- maybe you can just describe that process of building consensus in the community.  

AGARWAL:  Yeah, I think that's very critical, because we -- both in Bangladesh and Nigeria, we've realized that their societies are different enough that they wouldn't interact fruitfully if we tried to combine both male and female groups.  So we worked separately with the men's groups -- male group, including religious leaders.  

And one of the really interesting -- it's a personal anecdote again, but one of the really interesting meetings I went to in Bangladesh and Nigeria was that they would have a picture of a -- they would draw a full figure on the ground and have all the men stand around and say -- talk about what could go wrong with a woman when she's pregnant and then talk about solutions.  

So there would be a very open dialogue about -- you know, she could have hemorrhage, she could have this; and if she didn't want to have the pregnancy, she needn't have, you know, become pregnant.  So that open dialogue, I think, with the -- with the men really increased the understanding of the risks women face.  

I think they were also -- we promoted a lot of dialogue with the couples themselves so that they could communicate with each other about -- you know, and building upon what Mark was saying, that inter- household decision-making process, and then work with the religious leaders to be supportive of the decisions in that -- in that family and in that community so that they understood that it was coming from a health perspective and not a population-control perspective, and that these were important decisions that would have benefit to the community overall.  If women survived, their children would survive and they would -- they would be more productive.  

And another aspect that is -- that we added in the Nigeria context was -- again, it's -- one of the -- you know, the women said they would come forth and use family planning but they don't have access to resources.  And we started mothers' loans clubs, because they were able to use that to start small businesses, and then use emergency funds to come for family planning services when they need it or come and use services if they had a pregnancy complication.  

So sometimes we have to go beyond just the health side to make sure that you have the whole picture in perspective, to make -- to make -- enable the woman to seek the services that she is requesting, but I think that working with both men and women and making sure that the external environment is supportive of the women and the family's decision to use family planning is really important.  

COLEMAN:  And I'm sure that those women that I mentioned in Afghanistan, part of what was driving their demand for contraception was not simply they wanted to limit the number of children they were having so that they can pursue more economic opportunities, but the realization that one out of seven of them, statistically, is likely to die in childbirth, which is a really remarkable number.  One out of 4,300 women in developed countries is statistically likely to die in childbirth, one out of seven Afghan women.  

OK, I  -- well, let's take your questions.  If you wouldn't mind just waiting for the microphone, please introduce yourself and your name and affiliation.  That would be great.  Thank you.  Start here.  

QUESTIONER:  Hi.  I'm Penny Starr with CNS News, and it's for whoever wants to answer.  You mentioned 35 million abortions that have taken place.  Do you have a year?  Is that in a one-year period, or what's --  

COLEMAN:  That's one year.  

QUESTIONER:  One year -- what year was that?  Can you tell me?  

COLEMAN:  A recent year.  

QUESTIONER:  OK.  And then, I hear talk about access and mixing up family planning with abortions, but it struck me, that number, as showing that women in even developing countries have access to abortion, if there were 35 million performed; and I think that's part of what happens when you're saying family planning, abortion are connected. Do you have -- can you say where those -- how those -- they have access to that and yet don't have access, as you have said, for contraceptives?  It just doesn't seem to fit.  

COLEMAN:  Well, there -- 20 million of those 35 million abortions are unsafe abortions.  So I'm assuming that they're being done in very unsafe, unsanitary conditions, what we would call backroom abortions.  

QUESTIONER:  Yeah.  

COLEMAN:  You know, these are women who are desperate and are taking their life into their hands to abort a baby, and the reason that, you know, somewhere around 15 percent of maternal deaths occur from unsafe abortions, so many of those women will die.   

DYBUL:  And that is precisely the reason historically many social conservatives and pro-life, pro-family planning people have supported family planning, because it is a very effective method to reduce those unsafe or any type of abortion.  

You know, we were talking about data that surprised me.  The data that surprised me the most was actually how successful we've been at family planning.  I mean, to be at a point in global health where 200 million of 800 million -- (inaudible) -- we have very few things in global health where we receive that type of success where we're getting to 70 (percent), 75 percent coverage rates.  And we need successes in global health.  We need -- that's a success.  We've been able to get services out.  That means it's possible to do, it's relatively inexpensive to do, and there's demand for it.  

And that's -- that's something to actually say that's pretty remarkable, and -- but the danger is, as the population grows and as resources become more constrained, we'll be less and less able to meet that need.  

And so that's a very -- and that means we may have, again, more and more abortions.  So, again, we need to be aggressive to make sure that un-met need where people and individuals are making the decision to have birth spacing or control or limit the size of their family by different methods are able to do so.  

COLEMAN:  The other thing I would note is that, you know, a big portion of the abortions that occur in developing countries are girls between the ages of 15 and 19.  

DYBUL:  Yeah.  

COLEMAN:  It's quoted in this report.  I think it's close to 20 percent of -- I don't have the exact figure right here, but it's a large proportion.  I think it's 5 million of that number.    

And these -- you know, some of these girls, I mean, truly they're very desperate to be taking these actions.  And I don't know exactly where they're having abortions, but the fact is that in many countries, abortion is legal -- illegal, and yet women will still have abortions.  

AGARWAL:  If I may just add, I think it's -- just, as you said, it's clandestine.  It's in the back room somewhere.  Sometimes they're self-aborting using anything that they can lay their hands on. And sometimes they'll go to a traditional provider where there's confidentially and they will not be -- it will not be known that they're seeking that abortion.  So I think it happens in the most unsanitary and most unfavorable environment.  And these -- especially these women may end up with complications for life in terms of the septic complications and other things that may happen as a result of this abortion.  

QUESTIONER:  I'm Ray Martin from Christian Connections for International Health, which is a network of Christian organizations and individuals working in health in developing countries.  

Mark, you mentioned trust.  Can we discuss that a little more? In a survey that we conducted of our members, we found that all of them, including Catholics and evangelical Protestants, supported the concept of family planning if we clearly separated it from abortion, we insisted on respect of the cultural and religious sensitivities of communities, and if the choice of contraceptives was left up to the couple or the community.    

We -- we're observing the toxicity of the whole subject of family planning politically in this country.  And I suspect that part of it is because many people who might be supporters of family planning really believe that the organizations and people who are promoting and advocating for family planning really have an agenda that goes beyond family planning, and if we yield on family planning, then they're going to be at the door for federal funding for abortion and some of the other conservative issues that they don't want to yield on.  

And so I'm wondering, all of you and Mark, whether you can reflect a little bit more on how those of us who are supportive of family planning, including in the faith community, like my own organization, might help build a little more of that trust so that the fear and toxic reaction that many conservatives in this country have to the subject will be maybe not eliminated but at least reduced to some -- to some extent.  

DYBUL:  I think it's a very good question.  And, you know, around any issue, it doesn't matter what it is, there's -- there are dogmatists and -- that aren't interested in a conversation and aren't interested in building trusting relationships and aren't interested in compromise.  And this issue, like every other, is, we have some of those groups.  

And the unfortunate thing in this issue which you don't have in other issues -- although you do have in a lot of others -- is the room for error is almost nonexistent.  So there's a very tight line.  And in a lot of issues, you've got a lot of room to fall off that line. If someone says something in a conference or in a report and it offends someone, you know, there are a couple calls and you're done and it's over with and everyone gets back to the conversation they were having before.  In this particular issue, you fall off that line just a little bit on either side and you could shut down conversation for six months to a year.    

And everyone, you know, through their Internet bases are sending out notes about what horrific people these are.  

And that's -- we just have so little room for error right now. And that's what we need to get past.  We really need to get past the -- we need to get back to the point where the line -- you've got a lot of room to fall off the line because there's an open dialogue, people know each other and trust each other.  

And there are some real tough conversations that have to be had around that, and people have to be honest with each other.  You know, I -- there's almost been built up a sense that someone who doesn't -- who is having difficulty supporting family planning because of the abortion issue has no concept of the difficulty of that moment, of that young girl who's going into a back alley and the incredible trauma.  And I've seen people who have difficulty even with family planning break down crying because they've seen that experience.  It's not because they don't care about those people or, you know, are dogmatically opposed.  They're struggling themselves.  

And it's the same in the other direction.  There are a lot of people are -- who support abortion but understand the difficulty of that moment for a woman to come up with that decision or her partner. And the experiences you've had -- and you've had on the ground, we need to get back to that frame where people understand that people are struggling in a very emotional way with a very difficult issue and are wrestling with how to -- how to handle this issue as opposed to where we are today, which is largely people on the far end throwing bombs at each other.  And as soon as anyone falls off that line in any little way, they're almost deemed as evil.  

And that just isn't -- you can't have this conversation in that circumstance.  And so we need -- and it's not -- it can't just be the faith groups talking to each other.  That's the problem.  That's what we have; we have the groups who generally agree with each other talking to each other instead of having really the solid 80 (percent) to 90 percent in the middle who want to have a conversation, who want to listen to each other, who want to build that trusting relationship, knowing that there is going to be disagreement.  

But we do this in so many other areas in government where we have the circumstance, but you can have a conversation.  And when you have to get down to a vote and there has to be a compromise, people understand the compromise on why it was done and how it was done, not,  you know, vilifying someone because they compromised because they had to compromise.  

And we're not there yet.  And that's what I think this report can help us get to.  But it's going to have to be a -- it can't be a conversation just with Christian connections and your members.  It has to be a conversation -- maybe starting there but then broadening out so that we're reaching across the perspectives and having that dialogue.  And it's going to be tough.  It's going to be awfully tough.  And it takes a lot of work and it takes an enormous amount of commitment on all sides, but we have to do it.  We don't -- we have got to do it.  And that's -- you know, the data that are in this report and the data that we all know, we've got to do it.  We can't let lives hang in the balance because of this type of debate here in Washington.  

COLEMAN:  (Off mic.)  

QUESTIONER:  Thank you.  My name is Suzanne Ehlers.  I'm with Population Action International.  I had a question for both speakers -- I guess, Mark, maybe from a more political perspective; and, Koki, from a field-experience perspective.  Since we're in a room with friends, we know the cost-effectiveness of this interventions, we have enough evidence to sort of make the case, it makes good sense, et cetera, et cetera.  

And I guess I'm wondering -- especially mindful of Mark's comment that this last budget battle was a sandbox compared to what we have ahead of us -- how do we make, as a family planning and reproductive health community, make better liaisons and sort of connections with other development sectors?  And where would you see the sort of most traction that's not yet been exploited?  

I mean, PAI does a lot of this work at the intersection of family planning and the security piece, of course, with Liz's work.  We do it around the environment and climate-change adaptation.  Do you see additional room for movement there to sort of insert family planning's kind of primacy and centrality -- not the silver bullet, but a very important sort of tool -- in either those movements that we haven't maximized or in other development sectors -- security, water?  Just moving forward, we're going to have to make those partnerships really powerful in order to get the funding that we know this issue deserves.  

So I just would love some of your reflections, again, from kind of a Hill perspective and what you think would sort of hold water; but then also from a field perspective where you've seen in Nigeria, Bangladesh, what are people talking about in terms of the really natural connections between issues?  

DYBUL:  (We'll ?) start from the field, because that's where it matters.  

AGARWAL:  (Chuckles.)  Okay.  Well, I think that -- you know, definitely some of the connections that you mentioned -- food security is an important one; agriculture -- working with agriculture and inserting family-planning messages and services that are possible through other mechanisms and other development sectors that work and have funding to reach women and families.  

I think another big area that we haven't tapped into very much and now is much more open is using some of the Global Fund funding as well for an integrated and more directed funding for reproductive and women's health issues, which have been typically only funding TB, HIV and malaria but is much more open.  So I think exploiting some of these funding sources that have typically been meant for single- disease vertical interventions but to look at how we can expand them to make sure that we are addressing family planning, especially at the period where they come together.  

Like, let's say postpartum family planning, where you are reaching -- you're addressing prevention of mother-to-child transmission but also looking at the needs which are most immediate for women to prevent future pregnancies at that point.  How do we make sure that we are able to link the funding and link the ability to make those programs work together?  So within health, I think there's opportunities and then definitely, beyond health, if we can link with other sectors, there would be good opportunities.  

DYBUL:  You know, from a -- from a more political perspective, I think, though, the key points Koki just made -- it's about health.  It's about the health of the mother and therefore the neonate and the child, and it's about reducing abortions and the after-effects of abortions.  I think that's the -- that's going to resonate across aisles.  

And I do think the report starts mentioning -- and Koki just mentioned -- some of the links that -- and some of the difficulties that can arise in part -- and, again, we need to be careful, and I think, again, Isobel did a great job not saying this is going to be the solution to climate change or the solution to food.  

But to be honest, the general reactions of most people as they start making those links is usually not pretty good.  It looks like you're reaching for something that isn't there, and you have to be awfully tight on those linkages and how it fits together, or things can unravel pretty quickly, and it looks like you're trying to make a point that you don't need to make.  

The points for family planning on health alone and abortion alone are strong enough and will have enough support, I think, to carry -- as long as the conversations are being had and the -- and the -- and there's care and respect around those conversations, but talking about how we're already -- we're doing pretty well now on unmet need if we  get a little bit further, but as population grows, this problem's going to get more and more difficult.  Just from a family planning perspective, your unmet need is growing.  It's very difficult to catch up with that.  And that has implications.  And I think some of the data on size of population related -- mainly due to -- with poverty and therefore instability are important, too.  

But, again, if it's -- if it's -- if the argument is kind of being made we need to control the population because of these problems down the road -- and people have heard about -- I mean, the Malthusian nightmares, which are all of this stuff -- we used to do this in AIDS. We used to say, oh, if we don't tackle AIDS, all these huge problems in the world aren't going to be solved.  Well, it never wound up being true, a lot of them.  We way overreached, and that actually hurt our advocacy.  It didn't help our advocacy.  And people have kind of pulled back to be sure you know what you're talking about and make sure those links are tight.  But here there are -- there's a relationship, and that's the -- that's the kind of -- the line of argument, that there are relationships, that there are these deeper issues.  

But bringing it back to -- if we meet the unmet need, if we allowed those families to make the decisions around their size, if a family decides to have six children, if it has the tools, that's just fine.  If a family decides that they want to space their births and they want to have fewer children because that's how they can have a healthy and loving family, that's fine, too.  And we know that if that unmet need is fulfilled, based on that decision, some good things can happen both in health and other things.  

But what really worries me is that we get too far out in front saying here's the goal on national security and -- (inaudible) -- and other things, and birth -- that's going to -- that actually can undermine advocacy if we're trying to get across aisles.  And I worry very much about these cycles in family planning.  You know, depending on who's in and who's out, we go up and down and up and down.  And that's not good for the people on the ground and that's not good for anyone.  We've got to get past these cycles and get to a place where we're at a steady state and steady support.  

COLEMAN:  The only thing I would add to that is that we're talking about an increasingly concentrated problem.  You know, it really is.  If you look at the top 50 countries with the highest fertility rates in the world, all but, I think, three of them are in sub-Saharan Africa.  And -- you know, and those three are Yemen, Pakistan and Afghanistan.  So, I mean, these are -- you know, this is a -- this is becoming a very concentrated problem.  

And maternal mortality is also a highly concentrated problem.  And the two are linked; you know, they're very correlated.  And I think we should be cognizant of, you know, where -- the number, Mark, that you're using of 215 million, it kind of blurs.  

DYBUL:  Yeah.  

COLEMAN:  Because it's not -- you know, some countries, there are developing countries that have 70 percent of women are using contraception, and then you just gave the statistic in Nigeria of 1 (percent) to 2 percent.  I mean, there's huge disparities, and we should be cognizant of what those disparities are and how that links to the -- you know, some of these least, you know, stable states.  

Back there.  

QUESTIONER:  (Jodie Allen ?), Pew Research Center.  

A question that was posed before made me think that maybe there's an angle you should stress a little more.  This question of, "Oh, where did they get the 35 million abortions?" seemed to imply that some people might think that these abortions were being provided by Planned Parenthood or other organizations.  And of course, abortion -- and infanticide, which should not be ignored either -- have been the primary methods of birth control since the dawn of time.  And indeed, there's a very interesting -- you've probably seen it -- Scientific American study from a number of years back showing how well population correlates with economic conditions, because primarily of abortion and infanticide.  

And it may be that you need to stress that more; that people think that when you say, oh, well, you can prevent these abortions, they think, well, the abortions wouldn't happen if you people weren't subsidizing them.  And of course, that's not true.  There are back alleys; many of them are self-inflicted.  Maybe that's worth stressing more.  

COLEMAN:  Thank you.  That's a good point to make.  

QUESTIONER:  Thank you so much.  Jeff Spieler, from USAID.  I've worked in international family planning for 39 years.  

COLEMAN:  You're one of those experts who knows much more about this topic than I do.  (Laughs.)  

AGARWAL:  Yes.  (Laughs.)  

QUESTIONER:  I'm one of the people you didn't call on -- but that's quite all right.  And I haven't read the report yet, and I look forward to reading it.  But I did look at the references, and one of your references is the "Adding It Up" report by Guttmacher.  And when you read that report, you won't -- with a couple of exceptions, you will not find a developing country with 70 percent contraceptive prevalence.  

So let me tell you what -- some of the things that report says. In sub-Saharan Africa, of all women of reproductive age, 64 percent have an unmet need.  In West and South Asia, of all women of reproductive age, which is 15 to 49, 40 percent have an unmet need. So the unmet need is much higher in Africa, but numbers-wise, Asia is much larger.  

COLEMAN:  Much larger.  

QUESTIONER:  In other Asian countries, 32 percent of women have an unmet need.  In Latin America, it's down to 29 percent.  

Another important thing is, I think we really need to figure out our messaging, and what audience are you talking to -- and Mark was speaking very much to that -- and what's your message.  And maybe in some communities the correct message isn't the other advantages of family planning besides the health rationale that Mark was stressing so much.  Yet we don't want to forget those other important advantages.  And we continually make those long lists.  One, they include -- of the eight MDGs, you can't achieve seven of them without trying to help couples prevent unintended pregnancies.  

The effect of population growth that will very easily be dealt with through voluntary family planning and giving women and men access to a wide range of contraceptives, the -- nevertheless, the effect on natural resources; on water, sanitation; on food; on environment; on climate control; on state stability, which is mentioned in the report, because I quickly perused it; and just as important, on infectious zoonotic diseases -- those are the diseases that are transmitted from animals to people -- population -- (inaudible) -- an incredible ability to expand the zoonotic diseases.  

The last thing I'd mention:  Koki, thank you so much for mentioning the comparison between Bangladesh and Pakistan.  It's one of our favorite comparisons.  And interestingly, Bangladesh reached a total fertility rate of 3.0 in 2001.  Pakistan is -- at the current rate, will not reach a 3.0 total fertility rate until the year 2021.  

And looking at what that means in terms of the potential for development in the country is tremendous.    

So why did that happen?  And it largely happened because of a governmental decision not to control population by limit -- telling people how many kids they can have, but through the Matlab project and then the expansion and the provision of voluntary family planning.  So this is the answer to our question.  

And again, I'd just repeat myself, that this debate between abortion and family planning -- I think the two ends of the pole, bell curve, is 5 percent on both ends.  No matter what you tell both ends -- that's the right and the left -- you're never going to convince them.  So the 5 percent on the far right, you'll never convince them that family planning isn't abortion.  And even some of our methods are abortifacient.  So I'm arguing all the time that the oral- contraceptive pill and the IUD are -- do not promote abortion, nor does emergency contraception.  We have the scientific evidence for that.  

On the far left, there is a group of people who are strongly in favor of family planning, yet they will never get into this debate because they think anything that delegitimizes the importance of safe abortions -- of access to safe abortion services is not some bandwagon I want to get onto.    

So the more we think about -- and it is the fact that abortion has never been a method of family planning.  Nobody has considered it a method of family planning except in the rare -- certain countries, in certain conditions.  But internationally, we've never considered it a method of family planning; it was a last resort.  But that -- people -- some people on our -- contraceptive side don't want to even hear that story.  They don't want you to do anything to delegitimize safe abortion.  

QUESTIONER:  Thank you.  

COLEMAN:  I do -- I do recommend and urge all of you who are -- who are really engaged and interested in this topic -- and even those of you who may not be -- to read the background papers that we commissioned.  And three of our background paper authors are here. Koki is one.  Geoff Dabelko is here, and Liz Madsen.    

And Liz did a really, really interesting paper looking at the connection between demographics and security.  And there's some very,  very remarkable data in there looking at the correlation of very high youth populations and instability.    

And all of the challenges that states face with very rapid population growth -- and Geoff did a very interesting paper looking at the environmental implications of rapid population growth.  And, you know, clearly, while there's an element of looking at climate change and the impact of demographics on climate change, there's also, you know, very, very real resource constraints over in particular water and arable land.  And so I recommend both of those papers.  

And then the fourth paper is by Joy Phumaphi, looking at the connections and the feedback loop between family planning, reducing fertility and actually achieving economic growth.  And I think that's a very interesting topic, because there's been a lot of debate on this topic.  You know, do -- does actual -- you know, you need rapid population growth to drive economic growth -- and in fact, there's a lot of data that shows while rapid population growth can be a source of economic growth, not always.  And when you reduce population growth, you can actually achieve high per capita economic growth.  So I do recommend all of those papers.  

Right here.  

QUESTIONER:  Katherine Marshall from Georgetown University.  I'd be curious your comments about the international politics of this issue. The focus here is very much on the domestic.  And in many circles, people are completely bewildered by the American positions on these issues.  So I'd be curious as to how it's playing out.  We also know about the unholy alliances, so to speak, that have -- that have influenced.  

And I'd also -- Mark, I'd be interested in a couple of illustrations of the going off the line.  In other words, what -- you were talking about the very, very sensitive set of lines -- just a couple of practical illustrations.    

And what are your recommendations or your strategic sense of the constituencies that could make a difference?  What is -- where do you suggest going on this one at this point to try to bring reason back into the conversation?  

DYBUL:  Let me start from the very beginning. Internationally, it depends on where you are.  

If you're in Africa, this is -- countries are very much, for the most part -- understand the debate we're having in the U.S.  If you're in Europe, they don't.  And so it really depends on where you are.  

But that actually in a lot of ways contributes to the problem we have here at home, because there's not a lot of sensitivity to the sensitivity in the U.S.  And one of the reasons we've gotten into trouble here, I think, is there are always efforts in international documents to push issues that are just impossible for some people in this country to accept, and so there's this perception of this international effort to undermine certain viewpoints in the United States.    

And so I think your point is a good one.  We not only have to have a domestic conversation, we have to have a better international conversation that includes all viewpoints and perspectives.  

On falling off the line, I really don't want to provide any because I don't -- I really don't think looking backwards and pointing fingers is ever a particularly useful exercise.  All it does it get people back into their corners.  So rather than talking about past problems that we've had, why don't we understand the context we're in today, however we got here, call a general armistice and talk, and sit down and talk.  

And to Geoff's point, I couldn't agree more.  The problem is, it's the edges of the bell curves that have sucked all the oxygen out of the room and there's no breathing room left for the conversations that we need to have.    

And so I -- and this gets back to the point that Ray (sp) raised a little bit earlier.  To me, it's really a conversation that needs to happen to some degree within people who agree with each other, so that everyone's agreeing that we can't do this on our own, this isn't good. There are bad things that are happening to women and children that we care about, and we can't let this continue to happen.  Doesn't matter which side; that's the case.  And maybe those conversations need to happen and then people need to come together.  And there are going to need to be avenues and venues for those conversations where people can be very honest and direct with each other in a respectful way and really try to understand each other.    

And when you understand each other, it's pretty easy to fall off the line.  You trust and know where someone is on an issue enough that  when someone says, in a forum like this where people are talking for a while -- I mean, someone always used to tell me if you do more than a 10-minute interview, you're going to say something you regret.  And that just happens, you know.  But when those things happen in a trusting -- where people know each other and respect each other and understand each other's point of view, even if they don't agree with them, that's fine.  You make a phone call.  Someone calls you and says, did you say that?  And you say, oh, I'm sorry, that's not what I meant.  And you're done, rather than three months of Internet exchanges on what a horrible person this human being is.  

And that's what we're missing.  And I actually think part of the problem would be looking back and saying, who said what, when, where, and what was the reaction.  Why do that?  Let's just go forward with the conversation on women and children are dying, we have these huge issues.  You know, we start looking at health issues, stability issues, you start narrowing the field awfully quickly, and it's true in this issue as well.    

Let's start having the conversations around -- and whether it's maternal health, unmet need, malaria, economic growth, you're talking -- you're narrowing pretty quickly.  Let's have conversations, and not just here, but have those conversations where you're talking with the people on the ground.  What are they going through?  What are their struggles? What are they looking for?  What do they need?  What does that mean for how we respond to their needs?  Because we're not a colonial power, we're a partner.  And then you can start breaking through all those.  But my guess is it's going to take two to three years of everyone to really get us to the point where we can have these conversations and stop these cycles.  

AGARWAL:  Can I just add to that?  I think this is really important.  From my perspective, I think looking at what we try and work at the country level, as well as what may be helpful at the global level, one would be, I think -- just going back to our colleague from CCIH -- if there could be more of a dialogue with the groups that have support for family planning and bring those voices more in the forefront so that there is that open dialogue and trust, as Mark has pointed out, so we can create that through different fora. We try and do that at the country level but also at the global level.  

I think another issue is really working at the community to make sure  that the community's voice is heard and the women's voices are heard, and whenever possible, if we can then communicate that personal story; I think the story of somebody who's making the, you know, tough decision to make a choice, which could be abortion, which could be family planning.  

But just making those personal stories known, I think, may be also a powerful way of communicating our message.  

COLEMAN:  Let's do the first part of the question about the international environment.  You know, I think it's hard to generalize and I think, you know, there are people who -- when I talk about the anecdote I gave from Afghanistan -- you know, there are people who work on Afghanistan who say, oh, you can't talk about family planning in Afghanistan, it's such a conservative country.  

Well, they're talking about it.  You know, they want it.  They know about it and they want it, and they want it for a whole variety of reasons.  They want it -- some want it because they know they're going to die in childbirth.  You know, it's just a matter of odds. Some want it because they've had eight children and they cannot afford another child.  You know, some want it because the woman is the sole provider of her family and she has to take care of all these dependents.  I mean, there's a whole variety of reasons why women want it.  And you also find support among a lot of men.  You know, they recognize the need for it.  And there's a real range both within countries and between countries.  

You know, I see a country like -- look at Rwanda, coming out of, you know, a horrific genocide.  I was asked a question earlier, well, you know, what about countries coming out of genocide?  Did they want to beef up their populations?  Well, guess what?  Kagame, you know, recognized that family planning was a way to help his country recover, you know, to empower women and to help make people more economically independent.  

You know, I was in Rwanda a year ago.  It's a very small country with a lot of people.  And, you know, you come off the airplane in the airport, there's a huge sign that says plastic bags are illegal and everybody use a condom.  You know, and it's -- they're so far beyond where we are, you know -- (laughs) -- in terms of family planning in many ways, you know, in terms of the discussion that they're having. So, I mean, it really runs the gamut.  

Back here.  

DYBUL:  Although even there they -- what I meant is that the abortion issue is a huge issue.  And abortion, with the exception of a few countries, it's still -- it's still -- in Rwanda, and that's where the -- yeah --  

COLEMAN:  Yeah, yeah, yeah.  Yeah, yeah.  Absolutely.  Oh, yeah.  

QUESTIONER:  I'm Edwin Williamson from Sullivan & Cromwell.  I found this a very fascinating discussion.  I must admit that I have really sort of, you know, observed the whole family planning issue sort of out of the corner of my eye, and I -- and the misperception, I'll admit, that I probably had was family planning equals an attempt to decrease population growth by any means, and mainly abortion.  

But I also associate it with an anti-economic development attitude.  And I think one of the things that would help, as we see now that economic development is an extremely important factor in decreasing fertility rates and that this -- the family planning message needs to -- we just need to make sure that it is also accompanied by a pro-economic development message.  

COLEMAN:  Thank you.  And I do -- again, I recommend the background papers.  But we do look at that in this report, because I think there is a perception that you need fast population growth to drive economic growth, and the fact is that the fastest -- from a population perspective, the fastest-growing countries are the poorest countries in the world, and they are trapped in a very vicious cycle of poverty that they cannot break.  

And family planning is not a silver bullet, but it is one intervention that can help break those cycles of poverty by giving women the tools to choose, you know, when to have children, how many children to have.  And,  you know, these are some of the very, very poorest countries in the world. You know, the fertility rates are almost, you know, perfectly correlated with -- highest fertility countries are really the poorest countries in the world.  There's some outliers, but almost.  

DYBUL:  And I -- what you said, I think, is exactly right, and I would just emphasize that this is a good line of argument, to me, as opposed to, for example, climate control.  So, you know, climate change is the same -- is in the same category as development, and you're preaching to the same choir when you're making that point, whereas if you start talking about economic growth, you have different chorus lines, and talking about the relationships and the reality that population growth can help stimulate but can also hinder depending on where you are and the circumstances around you.  

COLEMAN:  Right.  

DYBUL:  And having those conversations related to economic growth, I think, is an important -- could be -- but couched in the terms of this is not the solution.  I mean, there's a lot of other -- simply reducing population isn't going to lead to economic growth.  

You have to have a lot of other stuff.  But it's a factor, and it's a factor that can contribute.  And, again, if you bring it back to let families decide how they can be economically sound on their own, which leads to economically sound communities and nations, then I think you can make a good argument.  

COLEMAN:  One of things we look at in the report -- again, you know, this is a concentrated problem.  And as I said, of the top 50 highest fertility countries, 47 of them are in sub-Saharan Africa. And in the last decade, sub-Saharan Africa has actually experienced remarkably robust economic growth as a continent.  And yet, rates of poverty have increased.  And it really is because the economic growth was not sufficient to keep up with the population growth.  And you were -- this is the vicious cycle of poverty that I'm talking about, and we talk about some of that in the report.  

I think we have time for -- just over here -- last question.  

QUESTIONER:  Thank you.  Susan Cohen from the Guttmacher Institute.  And I had nothing to do with Jeff promoting the report that we did with -- (inaudible).  (Laughter.)  

And also having worked in the field for many decades, it's very hard to even know where to jump in on some of the conversation, but I'm going to pick one, and that has to do with language and messaging.  

On the language issue, I think one thing that might help a teeny bit is to not always stick to the words "family planning" and to be clear that mostly what we're fighting about is contraception and contraceptive use.  My first boss when I came to the Guttmacher Institute, who was working in this field at the time that the domestic and international U.S. programs were created, always reminded me that that term "family planning" was used by members of Congress as a euphemism for birth control and contraception because they were too uncomfortable using those words.  

But ironically, in the anecdote you told us, Isobel, of the woman in the back of the --  

COLEMAN:  She didn't say, I want family planning.  

QUESTIONER:  She didn't say, give me my family planning.  

COLEMAN:  No, she didn't.  

QUESTIONER:  That's not the way -- that's not the way real people talk.  

COLEMAN:  Right.  

QUESTIONER:  They say:  I need birth control.  And most real people aren't -- don't have negative connotations with that term.  

So I think that would help a little in convincing the people who are willing to hear that we're not talking about abortion when we're talking about contraception.  There will be those who insist, as Jeff said, that some methods of contraception are abortion.  There's nothing you can tell them that will change their minds, but we're not talking to them, because, as I've quoted Melinda Gates many times, the only place contraception really is controversial is in the halls of the U.S. Congress, not in most Americans' -- and not with women around the world.  Anyway, so that's one point.  

But getting to the larger messaging, the value of the report that you've done is, as you pointed out -- it's not so much because there's anything new.  It's because you're saying it; it's because it's coming from the Council on Foreign Relations.  And I guess what I wanted to know from you about that is, what is the next step that you are taking in trying to reach out to the foreign-policy community, economic- development and economic-growth community and you taking the messages that we have been unable to get through to people because we're the wrong messengers?  

COLEMAN:  Well, the report, you know, was -- officially came out today and was received today by 600 influential people with a cover note from the Council on Foreign Relations; 25 VIPs got it with a cover note from Richard Haass; and 575 got it with a cover note from Jim Lindsay, the director of studies.  

So the council will write about it in our chronicle.  We're going to -- I have an expert brief that went up on the website today.  We're doing a lot of promotion around it.  And then I'm doing a lot of sort of side meetings with different groups -- State Department, DOD -- and on the Hill.  

So it's a whole range of different things, and some, you know, derivative pieces coming out of the report, some op-eds, some other pieces.  And some of our study group members are also writing some pieces related to the report, too.  So, you know, we hope that you here in the audience will help distribute and reverberate the message.  

So on that note, we do need to conclude, and I really thank you all for coming.  And this is a tricky subject, one -- I admit it -- I was reluctant to take on, but I'm glad that I did.  And please -- I think all of you can have a role in helping, you know, disseminate the report.  

So thank you, and thank you to Mark and Koki and to Jeff -- (off mic).  (Applause.)

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