The need to address excruciating health care inadequacies across Africa is focusing new attention on population growth, and Rwanda is leading the way. Best known for the genocide that overwhelmed it 13 years ago, Rwanda may seem an unlikely source of leadership in this regard, but that just underscores the magnitude of the problem.
Health care across Africa is in crisis. In sub-Saharan Africa alone, there continue to be roughly 3 million HIV/AIDS infections per year, and access to anti-retroviral therapy is available to less than 10 percent of those who require it. Sub-Saharan Africa has 43 million orphans; the health care infrastructure is entirely inadequate, and poverty is pervasive. There are now 700 million abjectly poor people living on the continent.
In the face of this crisis, population growth becomes an inevitable focus of public policy, even in predominantly Catholic Rwanda. In 1994, roughly 15 percent of Rwanda's population was horrifyingly murdered, and yet since then, Rwanda's perpetually high population growth has already brought its overall population to levels far higher than before 1994.
Today, the nation has one of the highest population densities in the world and an average per capita income of only $280 per year. Fewer than 10 percent of women have access to family planning methods. The average Rwandan woman gives birth to six children - nearly three times the U.S. rate - and currently, Rwanda's population of 9.1 million will double by about 2032.
With more than 90 percent of the population reliant on agriculture for their livelihoods, the ramifications are staggering. There are already approximately three people per arable acre, and even with advanced agricultural techniques there is scarcely adequate land remaining to produce subsistence levels of food. Earlier this year, a 44-year-old woman came to one of the health centers that we support to give birth to her ninth child. In tears after the birth, she said that she had no way to feed any of her children.
Rwanda is fast becoming a perfect Malthusian storm. As a result, Rwandan President Paul Kagame has announced that he is preparing a major initiative on population control designed to reduce Rwanda's birth rate by at least half. The model for Rwanda, in this case, comes from Asia -- Thailand in particular.
Between 1965 and 1990, Thailand's fertility rate dropped from Rwandese levels to U.S. levels, and during the same period its per capita income -- a crucial factor in improving health care -- tripled. The bedrock of Thailand's success is just what Rwanda is considering today: universal access to free birth control methods; training of health care workers in every setting to provide these methods; and a national campaign in support of access to family planning services.
Thailand never had a goal of zero population growth. It never put in place the types of policies that were instituted in China to encourage one or two children per family, but by making family planning services widely available, Thailand has had remarkable success since 1970.
The Rwandan government recognizes that it doesn't have 25 years to achieve its goals as Thailand did, and is, therefore, formulating plans to achieve zero population growth as early as 2015 -- the fastest demographic transition in world history. In contrast to the more coercive methods of family planning used in China, the focus in Rwanda is simply on providing free universal access to family planning techniques. In the view of the government, the pent-up demand is already present.
To achieve this, the government is looking at increasing its own spending while reaching out to international donors to make the plan a reality. Further, it is examining new strategies to get the job done quickly, including a barrage of pro-family planning communications from the President's Office down to the village level, the roll-out of advanced methods such as Norplant II to every health center in the country, and "opt-out" family planning. The "opt-out" strategy involves briefing every patient at a health facility -- regardless of the reason for the visit -- on the advantages of family planning and the free offerings available. In one health center that has adopted this strategy, the enrollment in family planning services increased 20-fold in the course of one month.
Changing public attitudes on population growth is hugely challenging in nations where fertility rates have long been high. A hundred years ago, when infant mortality was staggeringly high (it has dropped substantially in the last few decades) and land plentiful, it made good economic sense to have as many children as possible. Today, economic realities have changed, and public attitudes are being impacted. A survey in 2005 found that 59 percent of Rwandese women wish to space or limit their births, even though they currently have no access to effective contraceptive methods.
Even the Catholic Church, a major force in Rwanda, where abortion is illegal, recognizes that population growth poses major challenges. As a result, a dialogue is evolving between the Rwandan government, the Catholic Church, and other partners to consider ways to further engage the Church in the promotion of contraception, including condoms to prevent the spread of AIDS and other infections.
For its part, the United States provides some funding for family planning in Africa, while excluding funds to any group that offers abortion services or counseling. Even without changing U.S. policy, there is enormous room for expansion of family planning programming, as it has become a very small portion of U.S.-supported projects. In Rwanda, for example, USAID-sponsored family planning represents less than 10 percent of overall U.S. funding allocated to health care.
Effectively addressing health needs, including HIV/AIDS, requires a broader approach from the U.S. government. Health care cannot be addressed adequately without tackling the overall economic context in which it takes place, and population growth is a crucial component of that context.
If the Rwandan government puts forward a cohesive strategy for family planning in the coming months, international donors should look hard at opening their purses to promote these critical efforts. Success in Rwanda could provide a template for dozens of other nations. The results would help propel African development forward, diminishing its crushing poverty and improving health dramatically.
The United States has a direct stake in that outcome, because improved health care services mean, among other things, better detection of new diseases. If such detection had existed when HIV/AIDS first developed, it might never have become the tragic pandemic that we know today.
Ruxin is Assistant Clinical Professor of Public Health at the Mailman School of Public Health at Columbia University and Director of the Access Project in Rwanda. Rosenfield is Dean of the Mailman School and served as an advisor to the National Family Planning Program of the Thailand Ministry of PublicHealth in the late 1960s and early 1970s.