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Fistula, Stigmatization, and Development
›Although obstetric fistula may not be as widely recognized as other maternal health issues, the Fistula Foundation estimates that over two million women and girls in developing countries suffer from this condition today. The World Health Organization has labeled it as “the single most dramatic aftermath of neglected childbirth.”
Obstetric fistula is a devastating condition often resulting from obstructed labor that can cause infections, incontinence, and even paralysis. The condition largely afflicts poor, rural, and illiterate women in developing countries who lack resources and access to emergency care and surgery, and sufferers often face an additional burden of social stigma.
Economic Development and Social Standing
Poor infrastructure and poverty significantly increases the occurrence rate of obstetric fistula. Lewis Wall, in an article for The Lancet, writes that “poverty is the breeding-ground where obstetric fistulas thrive.” Wall cites early marriage, low social status of women, malnutrition, inadequately developed social and economic infrastructures, and lack of access to emergency obstetric services as being major contributors of fistulas in developing countries.
Additionally, “postponing the age of marriage and delaying childbirth can significantly reduce the risk of subjecting young women to the arduous labor that induces fistulas,” wrote Sonny Inbaraj of Inter Press Service News Agency (IPS) in an article about how fistula makes social outcasts of child brides.
In most developing societies where child marriage is common, the social standing of women is defined largely in terms of marriage and childbearing. Child marriages are typically arranged without the knowledge or consent of the girls involved. The norms emphasize a girl’s domestic roles and de-emphasize investments such as education.
Stigmatization of Fistula
There is an undeniable link between fistula and social stigmatization. Rather than receiving assistance from their families and communities, women are often ostracized and in many instances exiled from their communities. This is especially true in developing countries where “the role of women is merely limited to providing sexual satisfaction for their husbands, [and] producing children,” said Dr. Catherine Hamlin, founder of the Addis Ababa Fistula Hospital, in an interview with IPS.
“Many women and girls with fistula endure lives of shame, misery, violence, and poverty,” said Agnes Odhiambo, Africa women’s rights researcher and author of ‘I Am Not Dead, But I Am Not Living‘: Barriers to Fistula Prevention and Treatment in Kenya, in a Human Rights Watch article. Human Rights Watch has focused on fistula, recognizing that birth is a human rights issue. Ignoring the issues of women and girls only diminishes progress on human rights and sends a message that says the rights of women do not deserve adequate attention.
Prevention Efforts
Thus far the fight to end fistula has attracted various government agencies and organizations including USAID, UNFPA, EngenderHealth, Maternal Health Task Force, and the Human Rights Watch. Outstanding individuals have also played a key role in fistula prevention efforts, like Drs. Reginald and Catherine Hamlin, Australian gynecologists who came to Addis Ababa in 1959 for temporary medical work, but after hearing heart-breaking stories from fistula patients, they decided to move to Ethiopia permanently and open the Addis Ababa Fistula Hospital. As the only hospital dedicated exclusively to women with obstetric fistula, the hospital provides care free of change, and has done so since 1974.
Although fistula has gotten some support and attention, the need to scale-up the prevention initiatives has never been greater. As a result of the “poverty and the stigma associated with their condition, most women living with fistulas remain invisible to policy makers both in their own countries and abroad,” wrote Inbaraj on IPS.
“Preventing fistula and restoring women’s health and dignity requires more than good policies on paper,” said Odhiambo at Human Rights Watch. Seriously tackling the issue will require much more than traditional medical and public health interventions – prevention efforts must also take into account underlying social issues, food and economic security.
Sources: The Addis Ababa Fistula Hospital, Campaign to End Fistula, The Center for Global Development, The Fistula Foundation, Human Rights Watch, The Lancet, World Health Organization.
Photo Credit: “Hauwa’u, 25, mother from Rogogo community,” courtesy of flicker user DFID-UK Department for International Development. -
PRB’s Population Data Sheet 2011: The Demographic Divide
›August 9, 2011 // By Kellie Furr“Today, most population growth is concentrated in the world’s poorest countries – and within the poorest regions of those countries,” write the authors of the 2011 Population Data Sheet, an analysis tool published annually by the Population Reference Bureau (PRB). The population projections between poor and rich countries are “stark and very sad,” said Carl Haub Haub, senior demographer at PRB, at the July 28 web-based launch of the Data Sheet: “We call it the demographic divide. It shows the vast difference that has developed between the rich and poor countries of the world.”
The Population Data Sheet offers insight on global population trends using detailed statistical information along 18 demographic, population, health, and environment indicators for more than 200 countries and regions. The data sheet is based on the latest projections of the UN Population Division. Carl Haub and James Gribble of PRB discussed the long-term implications of the data sheet’s projections during web-based launch that included open questions.
Conflicting Trends
“Even though the world population growth rate has slowed from 2.1 percent per year in the late 1960s to 1.2 percent today, the size of the world’s population has continued to increase – from 5 billion in 1987, to 6 billion in 1999, and to 7 billion in 2011,” write the authors in PRB’s July Population Bulletin, “The World at 7 Billion.” To put those population totals into perspective, it took from the inception of human existence until the year 1800 – a total of approximately 50,000 years – to reach the first billion.
Fortunately, the recent (relative) decline in global growth rate has already curbed what could have been a considerable surge in the world’s population: “If the late 1960s population growth rate of 2.1 percent – the highest in history – had held steady, world population would have grown by 117 million annually, and today’s population would have been 8.6 billion,” said PRB President Wendy Baldwin in a press release. However, the world’s population still grows significantly at 77 million people annually, according to the UN, and we’re slated to reach 8 billion in just another 12 years. How can this dichotomy of large population totals in the face of lowered fertility be explained?
The Phases of Demographic Transition
“To understand global, we actually have to think local,” said PRB in their film short, “7 Billion and Counting,” released alongside the data sheet. Individual countries go through demographic transitions at different times, and the disparity in where countries are along in their progression varies greatly.
A demographic transition essentially hinges on two trends: the decline of birth and death rates over time. These trends do not necessarily change simultaneously however, resulting in most cases, first, a natural increase (when mortality rates decline but birth rates remain high) followed by a natural decrease in population (when birth rates also decline). Though the timing and magnitude of these trends differ from place to place, there are broad similarities across countries which have been conceptualized as phases by demographers, such as Carl Haub and James Gribble.Phase one is characterized by high birth rates and fluctuating death rates, found in countries such as Niger, Afghanistan, and Uganda; typically only death rates decline in this phase. Phase two, encompassing mostly lower-middle income countries such as Guatemala, Ghana, and Iraq, is marked by a continued decline in death rates but only slightly lower birth rates. The potential for large population growth exists in these countries, as they still possess a large youth population.
Countries in phase three have yet lower birth and death rates and overall total fertility rates close to the widely-accepted replacement level of 2.1 children per woman; these countries are home to approximately 38 percent of the world’s population and include India, Malaysia, and South Africa. Phase three countries often still possess a disproportionately large working age population as an echo of their previous growth, which allows them to take advantage of the “demographic dividend.”
Finally, phase four countries have the lowest birth and death rates, with some even seeing negative growth as total fertility rate falls at or below the natural replacement rate; countries in this phase include most of Europe and other developed countries, such as Japan and the United States (though relatively high levels of immigration keeps overall growth higher).
The data sheet shows that most developing countries still remain in the earlier phases of demographic transition, especially those in sub-Saharan Africa and the Middle East. Relatively recent public health improvements in these countries have decreased death rates at a rapid rate, and though total fertility rates (TFR) have declined as well, they have not kept the same pace: “This lag between the drop in death rates and the drop in birth rates produced unprecedented levels of population growth,” wrote Haub and Gribble in the Population Bulletin.
A Tale of Two Worlds
The data sheet authors observe that poverty is strongly associated with countries which are stalled in their progression through the demographic transition:Poverty has emerged as a serious global issue, particularly because the most rapid population growth is occurring in the world’s poorest countries and, within many countries, in the poorest states and provinces…Relatively high population growth rates make it more difficult to lift large numbers of people out of poverty.
In her primer video on demographic security for ECSP, demographer Elizabeth Leahy Madsen said, “we are in an era of unprecedented demographic divergence,” and characterized the phenomenon of population trends moving simultaneously in different directions as “rapid” and “unprecedented.”
Haub used Italy and the Democratic Republic of Congo (DRC) as an example to illustrate the divide. Although both countries currently sit at around 60 million people each, Italy is only projected to grow by 2 million through 2050, while the DRC is projected to reach a staggering 149 million people. Italy has a gross national income per capita of about $35,000, whereas DRC has only $180 per capita, according to the World Bank.
This observation has been corroborated by other demographers: “In 1950, 68 percent of the world’s population resided in developing regions. Today that’s up to 82 percent. But in the year 2050, it’s projected to be 86 percent,” said demographer David Bloom on NPR’s global health blog, Shots.
Demography ≠ Destiny
A poor country is not necessarily tethered to its projections, which are based on assumptions, said the authors, “but when, how, and whether [the demographic transition] actually happens cannot be known.”
Low development indicators do not always dictate that a country will lag in a demographic transition. “Government commitment to a policy to lower [birth rates] has succeeded quite well in countries with a low level of development,” said Haub in a 2008 PRB discussion on the demographic divide. Bangladesh and Iran are two examples of countries that significantly affected their demographic trajectories in the 20th century with targeted programs.
Proactivity certainly plays a role, as the PRB “7 Billion and Counting” video puts it (see above): “Understanding how and why the world’s population is growing will help nations better plan for the future…and for future generations.”
Sources: NPR, Population Reference Bureau, UN-DESA, UNICEF, World Bank.
Video and Image Credit: “7 Billion and Counting,” courtesy of PRB’s Youtube channel, and stages of demographic transition courtesy of PRB’s 2011 Population Data Sheet. -
Watch: Aaron Wolf on the Himalayan and Other Transboundary Water Basins, Climate Change, and Institutional Resilience
›When Aaron Wolf, professor in the Department of Geoscience at Oregon State University, and his colleagues first looked at the dynamics behind water conflict in their Basins at Risk study, they found that a lot of the issues they’d assumed would lead to conflict, like scarcity or economic growth, didn’t necessarily. Instead they found that “there is a relationship between change in a [water] basin and the institutional capacity to absorb that change,” said Wolf in this interview with ECSP. “The change can be hydrologic: you’ve got floods, droughts, agricultural production growing…or institutions also change: countries kind of disintegrate, or there are new nations along basins.”
However, these changes happen independently. “Whether there is going to be conflict or not depends in a large part to what kind of institutions there are to help mitigate for the impacts of that change,” explained Wolf.
“If you have a drought or economic boom within a basin and you have two friendly countries with a long history of treaties and working together, the likelihood of that spiraling into conflict is fairly low. On the other hand, the same droughts or same economic growth between two countries that don’t have treaties, or there is hostility or concern about the motives of the other, that then could lead to settings that are more conflictive.”
Wolf stressed the importance of understanding hydrologic variability in relation to existing treaties around the world. After carefully examining hundreds of treaties, he and his colleagues created a way of measuring their variability to try to find potential hotspots.
“We know how variable basins are around the world; we know how well treaties can deal with variability. You put them together and you have some areas of concern: You may want to look a little closely to see what is happening as people try to mitigate these impacts,” said Wolf.
“We know that one of the overwhelming impacts of climate change is that the world is going to get more variable: Highs are going to be higher, and lows are going to be lower,” Wolf said.
Wolf used the Himalayan basins to illustrate the importance of overseeing the potential effects of climate change and institutional capacity. “There are a billion and half people who rely on the waters that originate in the Himalayas,” he pointed out. Because of climate change, the Himalayas may experience tremendous flooding, and conversely, extreme drought.
Unfortunately, Wolf said, “the Himalayan basins…do not have any treaty coverage to deal with that variability.” Without treaties, it is difficult for countries to cooperate and setup a framework for mitigating the variability that might arise. -
Beyond Supply Risks: The Conflict Potential of Natural Resources
›While the public debate about resource conflicts focuses on the risk of supply disruptions for developed countries, the potentially more risky types of resource conflict are usually ignored. As part of a two-year research project on behalf of the German Federal Environment Agency, adelphi and the Wuppertal Institute for Climate, Energy, and Environment have analyzed the risks of international conflict linked to natural resources in a series of reports titled Beyond Supply Risks – The Conflict Potential of Natural Resources.
Resource extraction, transportation, and processing can create considerable crises and increase the risk of conflicts in producing and transit countries. This phenomenon – widely referred to as the “resource curse” – impacts consuming countries only if it leads to shortages and higher prices. However, in the producing and transit countries it can have much wider destabilizing effects – from increasing corruption to large-scale violent conflict. In addition, the extraction, processing, and transportation of resources often create serious environmental risks. Overexploitation, pollution, and the degradation of ecosystems often directly affect the livelihoods of local communities, which can increase the potential for conflict.
The eight reports that comprise Beyond Supply Risks explore plausible scenarios over the next two decades, focusing on four case studies: copper and cobalt in the Democratic Republic of Congo; the Nabucco natural gas pipeline project across Southern Europe and Turkey; lithium in Bolivia; and rare earth minerals in China.
Lithium in Bolivia
Bolivia possesses the world’s largest known lithium deposits, a potentially important resource for the development of electric vehicles. While the development of Bolivia’s lithium reserves could provide major economic benefits for one of the poorest countries in Latin America, our analysis identifies two main potential risks of conflict.
First, the environmental consequences of developing industrial-scale lithium production might have negative effects on the livelihoods of the local population. The local population in the lithium-rich department of Potosí has shown that it is capable of organizing itself effectively in defense of its interests, and past resource conflicts have turned violent, making a conflict-sensitive approach all the more important.
Second, the Bolivian economy is largely dependent on natural resources, and consequently is susceptible to price shocks. At present, this risk is primarily associated with natural gas. But lithium production, if developed, might be subject to the same dynamics, which could potentially destabilize the political system.
For consuming countries, these conflicts threaten supplies of lithium only if local protests or broader destabilization were produce bottlenecks in the supply chain.
Rare Earths and China
Like lithium, rare earths are likewise essential for some new technologies. China’s well publicized monopoly on 97 percent of the global production spurred a heated debate on the security of supply of strategic minerals. While our case study identifies supply risks for consuming countries, it also outlines some of the conflict risks China might face internally.
First, local populations could protest against the severe ecological impact of rare earth mining and production. In addition, conflicts might arise if those who profit from economic development (entrepreneurs or regional power-holders) undermine the traditional centralized party structures and expand their own influence.
International conflicts over access to Chinese rare earth resources, while they dominate the headlines, do not appear to be the dominant risk. Instead, internal political tensions could result in a weakened China that is not able to exploit its monopoly position for foreign policy gains. Or the government could enter into multilateral agreements and thus avoid a confrontational approach towards consumer nations.
Ultimately, the actual rate of diffusion of environmental technologies and the development of new technologies remain the key factors in determining whether relative shortages in global supply of rare earths will in fact occur. If industrialized nations and emerging economies commit to the same technologies to attain climate policy goals, international resource governance and coordinated promotion of (environmental) technology will also play a role in preventing conflict and crisis over rare earths.
The Way Forward
The series concludes with five recommendations to mitigate the risks of future resource conflicts:- Introduce systematic policy impact assessments to understand how policy goals and strategies, especially in regard to climate and environmental policy, interact with resource conflict risks.
- Increase the transparency of raw material markets and value creation chains to prevent extreme fluctuations in prices and improve information on markets, origins, and individual players.
- Improve the coherence of raw material policy by linking raw material policies with security, environmental, and development policies.
- Demand and promote corporate social responsibility along the whole value chain.
- Increase environmental and social sustainability as a means of strengthening crisis and conflict prevention by systematically taking into account social and conflict-related aspects in the resource sector.
The individual reports from the project can be downloaded here:- Conflict Risks (GERMAN only)
- Supply and demand (GERMAN only)
- Case Study: Nabucco Pipeline (GERMAN only)
- Case Study: Congo
- Case Study: Bolivia
- Case Study: China
- Conflict Resolution Strategies (GERMAN only)
- Summary and Recommendations
Sources: Government Accounting Office.
Photo Credit: “Potosí: miners in darkness,” courtesy of flickr user Olmovich. -
Backdraft: Minimizing Conflict in Climate Change Responses
›“What are the conflicts or risks associated with response to climate change?” asked ECSP Director Geoff Dabelko at the Wilson Center on July 18. “How we respond to climate change may or may not contribute to conflict,” he said, but “at the end of the day, we need to do no harm.”
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Sajeda Amin on Population Growth, Urbanization, and Gender Rights in Bangladesh
›“One of the reasons why population grows very rapidly in Bangladesh is women get married very early and have children very early,” the Population Council’s Sajeda Amin told ECSP in a recent interview. “So even though they are only having two children, they are having them at an average age of around 20. As demographers would say, women ‘replace’ themselves very rapidly.”
Largely through the promotion of contraceptive use, family planning programs implemented over the past 35 years by the Bangladeshi government and a variety of NGOs have helped lower the country’s total fertility rate to 2.7 from 6.5 in the mid-1970s. To build on this progress, the Population Council has joined a consortium of other organizations – including the Bangladesh Legal Aid and Services Trust, Marie Stopes International, and We Can End All Violence Against Women – to launch the Growing Up Safe and Healthy (SAFE) project in Amin’s native Dhaka and other Bangladeshi cities.
Currently nearing the completion of its first year, the four-year initiative has several aims, among them increasing access to reproductive healthcare services for adolescent girls and young women and bolstering social services to protect those populations from (and offer treatment for) gender-based violence. The project also looks to strengthen laws designed to reduce the prevalence of child marriage – a long-standing Bangladeshi institution that keeps population growth rates high while denying many young women the opportunity to pursue economic and educational advancement.
A Focus on Gender and Climate
Amin says the SAFE project boasts several qualities that collectively set the initiative apart from similar-minded programs in Bangladesh dealing with gender and poverty. These include a strong research component incorporating quantitative and qualitative analysis; the holistic nature of the program, which incorporates educational outreach, livelihood development, and legal empowerment; a commitment to working with both male and female populations; and an emphasis on interventions targeting young people, with the hope that such efforts will allow adolescents to make better-informed decisions about future relationships and reproductive health, thus reducing the likelihood of gender-based violence.
Finally, while many existing gender-based programs focus exclusively on rural communities, Amin points out that the SAFE project also stands apart because of its focus on the country’s rapidly expanding urban areas. To date, the initiative is focusing many of its early interventions in a Dhaka slum that has seen an influx of rural migrants in recent years due to climate-change impacts in the country’s low-lying coastal areas.
“A lot of the big problems in Bangladesh now are climate-driven in the sense of creating mass movements out of areas that are particularly vulnerable or have been hit by a major storm,” Amin said. “Usually these are people who, once they lose their homes and their livelihoods, will have no choice but to move to urban areas, and that’s a process that is kind of a big outstanding issue in Bangladesh now.”
By building programming around girls and young women in such communities, the SAFE project is looking to spark change from the bottom up, prioritizing the unmet health and social needs of some of Bangladesh’s most vulnerable populations.
The “Pop Audio” series is also available as podcasts on iTunes.
Sources: Global Post, Ministry of Health and Family Welfare (Bangladesh), Shaikh and Becker (1985). -
What’s the Impact of Family Planning in the Developing World? ‘Science’ Magazine’s Population Issue
›“Does Family Planning Bring Down Fertility” in Science’s special July issue on population, author Jocelyn Kaiser engages various experts to explore whether family planning programs actually help to reduce high fertility. Social demographer Amy Tsui of Johns Hopkins University argues that surveys indicating “unmet need” in family planning “don’t tell us anything about causation.” On the other hand, Martha Campbell, a lecturer at the University of California, stressed that in countries such as Niger where the population could soar from 16 million today to 58 million by 2050, “You can’t expand [schools] fast enough.” Thus, focusing on family planning is indispensable and “the benefits [will] far outweigh the costs.”In “Population Policy in Transition in the Developing World,” also published in the population issue of Science, authors John Bongaarts and Steven Sinding explain why there has been renewed interest on family planning in developing countries. Since rapid population growth in the poorest countries is hampering development, “economists, once notably skeptical, increasingly acknowledge that fertility decline has beneficial economic effects for nations and families,” they write. Moving forward, Bongaarts and Sinding suggest family planning needs to be at the forefront of population and development discussions. Not only is family planning “cost effective,” they write, but it is responsible for “relieving population pressures, stimulating economic development, improving health, and enhancing human freedom.”
See the full line-up of articles from Science’s population edition here. -
Population, Health, and Environment Approaches in Tanzania
›“Quality of life, human health, food security, and biodiversity are all connected,” said Elin Torell, research associate for the BALANCED Project and the University of Rhode Island Coastal Resource Center. Torell was joined at the Wilson Center on July 19 by Patrick Kajubili from the Tanzania Coastal Management Partnership, and Alice Macharia, director of the East Africa Program at the Jane Goodall Institute to discuss the importance of integrated population, health, and environment (PHE) initiatives that work to simultaneously improve health and livelihoods, manage natural resources, and conserve ecosystems in Tanzania.
Building Resilient Coastal Communities
The Coastal Resources Center’s work in Tanzania’s Saadani National Park provides an example of an integrated PHE approach that sustains the flows of environmental goods and services, maintains biological diversity, and empowers and improves the wellbeing of local residents, said Torell. Since 1996, the CRC has focused on protecting sea turtles, promoting energy-saving stoves, and tracking elephants, while at the same time improving livelihoods through savings and credit associations, eco-tourism, and beekeeping.
“Adding family planning makes a whole lot of sense,” said Torell. There is a high unmet need for family planning in Tanzania and the population is growing rapidly with an average number of 5.6 children per woman. Family planning not only helps families limit and space births but indirectly works to improve food security and human health, reduce demand for scarce natural resources, and empower women, she said.
“Integration is key,” concluded Torell: A coordinated and synergistic approach that meets the varied needs of local communities will be more effective and sustainable than if interventions were delivered independently.
Effective Integration in the Field
“Conceptual linking is not enough,” said Kajubili. “Integration also needs to happen at the organizational and field levels.”
On the ground, the Tanzania Coastal Management Partnership integrates family planning education and services into conservation work, said Kajubili. Peer educators deliver information about family planning, health, and coastal resources management; and community-based distributors deliver family planning services and supplies.
“Now people easily access reproductive health services,” said Kajubili. To date, the program has increased referrals to health centers, promoted contraceptive use, and reduced the distance that women need to travel to receive family planning services.
“Integration makes sense and cents,” said Kajubili. By combining resources, health and natural resource management organizations can potentially reach a broader population while sharing costs.
But “reinforcing the linkages between PHE of course takes time and education,” said Kajubili, highlighting a major challenge to implementing integrated approaches. “Advocacy is needed to overcome cultural and institutional barriers.”
“What About Our Needs?”
“Socio-economic development; family planning and AIDS education; sustainable forestry and agriculture practices; and water and sanitation all underpin and support sustainable natural resource management,” said Macharia.
The Lake Tanganyika Catchment Reforestation and Education Project (TACARE) led by the Jane Goodall Institute was initiated in 1994 to arrest the rapid degradation of land through tree planting and forest degradation, said Macharia. “But at some point, the communities raised the question: What about our own needs?” she said.
Community members prioritized the need for health services, education, clean water, and financial capital. But environmental degradation was not seen as a major issue, suggesting a need for a more integrated approach to TACARE’s conservation efforts.
“Integrated programs including population, health, and environment activities are cost-efficient and add value to conservation goals,” said Macharia. By responding to the needs of the community, the integrated approach adopted by TACARE has gained more credibility among local people, while a strong focus on building local capacity has helped to ensure sustainability of the program.
While there are many challenges to implementing and maintaining integrated PHE programs, “partnerships at the local, district, and national level are key to making this a success,” concluded Macharia.
Sources: Population Reference Bureau.
Photo Credit: “Environment near Vumari Village,” courtesy of flickr user treesftf.
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