In Rwanda Amid Global Population Challenges President’S Note

Volume 51, Issue 1 March 2019

A Ray of Hope in Rwanda Amid Global Population Challenges President’s Note

he December 2018 President’s Note addressing the Of course, highly developed nations must dramatically reduce stunning silence regarding the impact of population emissions. And we cannot shift blame onto people struggling growth on climate change really struck a nerve with extreme poverty, looming pandemics, and civil strife —T resulting in unprecedented comments that this must be exacerbated by overcrowded conditions. Faced with few or no addressed. options, many flee their homes as a last resort.

Yet why do so many who recognize the dire threats posed by cli- Climate change is a global crisis. Everyone can help. Today, mate change refuse to accept the incontrovertible evidence that there are 214 million women in less developed nations who population growth is a key driver of greenhouse gas emissions? don’t want to be pregnant but who face barriers to using birth control. Here at home, nearly half of all pregnancies are still Pushback often takes the form of whataboutism: “What about unplanned. A modest investment in U.S. foreign assistance can our own sky-high carbon emissions? Why focus on rapid popu- help smash family planning barriers everywhere, so people can lation growth in less developed, low carbon nations when our have the lives they want, which nearly always results in smaller usage is the real problem?” families. They win. We win. The planet wins.

Some early references to whataboutism targeted the Soviet pro- It seems so obvious. What are we waiting for? paganda technique whereby U.S. criticism of totalitarianism was hit with the rejoinder, “What about all the lynchings in the American South?” Whataboutism is used to stifle discussion John Seager by pointing out some manifest failure on the part of those who [email protected] raise inconvenient topics. It’s all about evasion.

What’s small, sweet, wrinkled, and helping us meet the population challenge?

Raisins… Let me explain. agreement whereby he transferred ownership of the farm to Population Connection to establish a lifetime Charitable One of our longtime members owned an 18-acre raisin farm Gift Annuity, which provides him with guaranteed payments outside Fresno, California, thousands of miles from where he that will never change. We then sold the property, which is lived. A local farmer tended the land — providing income to still producing crops. the owner and to the farmer. Our generous donor and Population Connection both benefit After retiring, the owner of the farm decided to get out of the under the terms of the annuity agreement. raisin business. Crops are fickle, and he preferred regular payments without the headaches of remote ownership. If you’re looking to sell a raisin farm or any other mar- ketable piece of real estate, feel free to email Shauna at Shauna Scherer, our Vice President for Marketing and [email protected] or call her at (202) 974-7730. She’ll Development, worked closely with him. We entered into an be glad to work with you.

Population Connection — March 2019 Volume 51, Issue 1 March 2019

Features Board Chair Estelle Raboni, MPH, MCHES 10 Population Connection at the 2018 International Board of Directors Conference on Family Planning in Kigali, Rwanda Aaron S. Allen, PhD Andreea Creanga, MD, PhD 12 Rwanda’s Community Health Workers: Meeting People Amy Dickson Katie Ferman Where They Are Bryce Hach, MS Mark Hathaway, MD, MPH 14 How Rwanda’s Catholic Clinics Struck a Contraception Padgett Kelly, PhD Compromise Nejla Liias, MPP Sacheen Nathan, MD, MPH 18 Resiliency in the Face of Harmful Rhetoric From a Bob Pettapiece, EdD Dara Purvis, JD (Vice Chair) Heartless Leader Halfway Across the World The Hon. Tom Sawyer (Treasurer) Kevin Whaley, PhD 24 How to Grapple with Soaring World Population? An Hania Zlotnik, PhD (Secretary) Answer from Botswana President and CEO John Seager [email protected]

Editor Departments Marian Starkey, MSc 2 Editor’s Note [email protected]

Population Connection (ISSN 2331-0529) 3 Letters to the Editor Population Connection is the national grassroots 4 Pop Facts population organization that educates young people and advocates progressive action to 6 In the News stabilize world population at a level that can be sustained by Earth’s resources. 8 President’s Circle Cover Image: Annual membership ($25) includes a one-year A nurse who is a nun at a health clinic in Rwanda. 30 Washington View subscription to Population Connection magazine. © Riccardo Gangale/USAID, Courtesy of All contributions, bequests, and gifts are fully tax- Photoshare 32 Field & Outreach deductible in accordance with current laws.

Population Connection 34 PopEd 2120 L Street, NW, Suite 500 36 Cartoon Washington, DC 20037 (202) 332-2200 • (800) 767-1956 37 Editorial Excerpts [email protected] PopulationConnection.org PopulationEducation.org www.popconnect.org March 2019 — Population Connection 1 Editor’s Note

wanda, the host of the 2018 International Conference the atrocity, located on the site of a mass grave where 200,000 on Family Planning (ICFP), would be the perfect bodies lie beneath several planes of cement. destination for someone visiting sub-Saharan Africa Rfor the first time — especially someone who didn’t do well with With 12 million people living in a land area smaller than noise and chaos and small dangers at every turn. Kigali is clean, Maryland, which has a population half that size, Rwanda is the orderly, and full of fantastic restaurants serving international most densely populated country in continental Africa. Its popu- cuisine. During the five days I spent there — admittedly a lation is growing by 2.3 percent a year, at which rate it would very short stay and one that didn’t include any travel outside double in 30 years. With 60 percent of the population under the capital city — I was only approached for money once, the age of 25, with the bulk of their childbearing years ahead and when I declined offers of taxi rides or invitations to visit of them, population growth won’t slow down without contin- people’s shops, one polite response was all it took to conclude ued fertility reduction. When international family planning the exchange. In November, when the conference took place, programs first began in the 1960s, Rwanda’s total fertility rate the weather was temperate, if a bit rainy, which made walking was 8.2 children per woman. Today, it is 4.2 — still two births the safe streets even more enjoyable. above replacement rate,** but trending in the right direction. The UN Population Division’s medium fertility variant projects that These pleasant surprises caught me off guard because, as I’m Rwanda will reach replacement rate in the late 2050s, and con- sure many do, when I think of Rwanda I think of the 1994 tinue declining from there. genocide. I was ignorant about the impressive strides that the country has made since then to heal wounds, both physical and In order for that projection to become a reality, however, invest- emotional, and I was equally ignorant about what a popular for- ment in family planning must remain a top priority, along eign investment destination Rwanda has become. In fact, the with investments in education, health, and gainful employ- World Bank ranks Rwanda 29th in its “ease of doing business ment. United States foreign assistance plays a big role in that ranking,” the only low-income economy to make the top 50. investment strategy, and we cannot let our own country’s fickle policies, imposed by our so-called leaders, derail the progress Due to concerted efforts since the mid-1990s to soothe ten- that countries such as Rwanda have worked so hard to achieve. sions between Hutus and Tutsis, the two ethnic groups that massacred each other,* the only obvious evidence of the geno- Marian Starkey cide that I saw was at the museum and memorial dedicated to [email protected]

* The genocide was committed by extremist Hutus against Tutsis and moderate Hutus. Once the genocide was officially over, the Tutsi-led Rwandan Patriotic Army slaughtered Hutus — many of ** The UN Population Division estimates Rwanda’s replacement rate them guilty of committing direct acts of genocide — who had been fertility to be 2.2. Each country’s replacement rate is dependent on driven to refugee camps in the Congo. its particular mortality rate.

2 Population Connection — March 2019 Send correspondence to Letters to the Editor [email protected]. Attn: Marian Starkey Letters are also accepted via Population Connection postal mail. Letters may be 2120 L St NW, Suite 500 edited for clarity and length. Washington, DC 20037

I read with absolute agreement and frustration John’s President’s must be vigorously opposed for being as archaic, ignorant, and Note in the September 2018 issue of Population Connection, destructive as the medical practice of bleeding sick people to wherein he posed the question, “Is population a taboo subject?” treat illness. The clock ticks. Nathaniel Batchelder I think we all know the answer. John, I couldn’t agree more with your editorial. I am 62 years I have written upwards of a zillion op-ed pieces, which almost old. When I was 16, I knew there were too many people on this never get published due to this same general (cultural? political? planet, and I became a supporter of ZPG. I didn’t want children religious? economic?) fear of addressing this critical topic. and later my then-fiancé and I parted ways over the issue. I have chosen a childfree life, with no regrets. Human overpopulation is the single greatest threat we — as both a species and a planet — face, so it’s high time to make it Fast forward to 2018: I have become a monthly supporter of the biggest issue of our epoch! Population Connection. Robert P. Johnson As an environmentalist and animal protectionist, there are I read about women and birth control and abortions in every many quotes I live my life by. Here are two: one of your magazines. My question is: When are men going to step up to the plate and take responsibility for their part in “Humans: We’re not the only species, we just act like it.” the overpopulation issue? Why is it always up to women to deal – Attribution unknown with this? If men were more conscientious, there wouldn’t be so many unwanted pregnancies in the first place. It’s interesting “Anyone who believes that exponential growth can go that there is no birth control for men, but there is Viagra so men on forever in a finite world is either a madman or an can have sex later into their lives. Oh bother!!! economist.” Bonnie Scott – Kenneth Boulding (an economist himself )

I was shocked to see in John Seager’s December President’s Note I don’t know why we refuse to address the issue. Ego? For peo- that the IPCC’s recent Summary for Policymakers contained ple planning a family, I would like to ask them three questions: not a word about population growth’s impact on the climate 1. How many people do you think the planet can support? crisis. Do not human numbers grow by 80 million annually? (Most say there are too many already.) 2. How did you deter- mine that number? 3. How will we stop population growth We must all shout from the rooftops that every woman deserves when it reaches that number? Of course, they don’t have an ready and affordable access to contraceptive and birth control answer for any of these questions. information and services. Political and religious opposition Lawrence Arkilander www.popconnect.org March 2019 — Population Connection 3 Unmet Need for Family Planning and Young women Unintended Pregnancy Among often report several reasons for not using ADOLESCENTS contraceptives despite not wanting a pregnancy:

INFREQUENT SEX

Roughly half of NOT BEING MARRIED pregnancies CONCERNS ABOUT among adolescents In Africa, nearly CONTRACEPTIVE SIDE EFFECTS aged 15–19 in two-thirds BREASTFEEDING OR (62%) NOT HAVING RESUMED developing regions MENSTRUATION AFTER A BIRTH of sexually active are unintended, adolescents wanting THEIR OWN, THEIR PARTNERS’, and about half of these OR OTHERS’ OPPOSITION TO to avoid pregnancy end in abortions, most CONTRACEPTION experience unmet need. of which are unsafe.

Each year, if all This would result in 2.4 million fewer adolescent women unplanned births; 2.9 million fewer 20 million who need modern abortions, of which 1.9 million would contraceptives were to have been unsafe; 763,000 fewer adolescent women in the miscarriages and stillbirths; and 6,000 use them, unintended developing world have an fewer maternal deaths. Most of the unmet need for modern pregnancies would maternal deaths averted would be contraception. decrease from 20 in Africa (4,300), the region with the million to 14 million. world’s highest maternal mortality.

Source: “ADDING IT UP: Costs and Benefits of Meeting the Contraceptive Needs of Adolescents in Developing Regions,” Guttmacher Institute, November 1.

4 Population Connection — March 2019 Design by Mali Welch Unmet Need for Family Planning and Young women Unintended Pregnancy Among often report several reasons for not using ADOLESCENTS contraceptives despite not wanting a pregnancy:

INFREQUENT SEX

Source: “ADDING IT UP: Costs and Benefits of Meeting the Contraceptive Needs of Adolescents in Developing Regions,” Guttmacher Institute, November 1.

www.popconnect.org March 2019 — Population Connection 5 In the News

Federal Judge Blocks Kenya Bans Marie Stopes said the Mississippi legislature’s “pro- Trump Administration International from fessed interest in ‘women’s health’ is pure from Expanding Birth Providing Abortions; Then gaslighting.” Control Exemptions Reverses Ban In November 2018, the Trump admin- A misunderstanding about radio ads the An identical law in Louisiana was istration finalized new rules expanding UK-based organization Marie Stopes automatically struck down because of employer exemptions to the birth con- International (MSI) was running in its contingency on the Mississippi law trol benefit of the Affordable Care Act Kenya led to a directive in November being upheld. (ACA). that they stop providing legal abortions and post-abortion care in their clinics. Mississippi’s Democratic Attorney The new exemptions would allow The ads were interpreted as promot- General, Jim Hood, filed an appeal of the employers that have religious objections ing abortion, but MSI argued that they judge’s ruling in December with the 5th to birth control to cease providing con- simply aimed to create awareness around U.S. Circuit Court of Appeals. traceptive coverage in their employee the dangers of unsafe abortion. Abortion Hormonal Male Birth health insurance plans. They would also is only legal in Kenya when a woman’s Control in Testing Phase allow employers, as long as they are not health or life are threatened. publicly traded, to stop covering birth The National Institutes of Health (NIH) control if they have a moral objection to After an audit of the organization’s pro- is conducting a test of a contraceptive gel its use. The new exemptions would also grams, the Kenyan Ministry of Health for men. The gel, called Nestorone, is a apply to educational institutions that determined that MSI was not in viola- combination of progestin and testoster- provide health insurance to students. tion of Kenyan law, and resumed MSI’s one. It is applied daily to the shoulders permission to serve patients. and back and works to halt the produc- The day before the new rules were Judge Slams Mississippi tion of sperm without eliminating men’s scheduled to go into effect ( January 14), Abortion Ban libidos. District Judge Haywood S. Gilliam, Jr. issued a preliminary injunction, tempo- In November, U.S. District Judge Carlton Diana Blithe, one of the study’s research- rarily blocking the rules for the 13 states Reeves struck down a Mississippi law ers, says, “Many women cannot use plus D.C. that challenged the exemp- that banned abortion after 15 weeks of hormonal contraception and male tions in court. pregnancy. The law was signed in March, contraceptive methods are limited to at which point the sole surviving abor- vasectomy and condoms. A safe, highly The following day (the day the rules were tion clinic in the state sued and received effective, and reversible method of male scheduled to go into effect in the states a temporary restraining order, which pre- contraception would fill an important that weren’t part of the lawsuit), U.S. vented the law from ever being enforced. public health need.” District Judge Wendy Beetlestone issued a preliminary injunction blocking the Judge Reeves wrote in his decision, “The The gel was developed in partnership rules for the entire country. State chose to pass a law it knew was with Population Council. It will be tested unconstitutional to endorse a decades- on 420 men in Los Angeles and Seattle, Legal challenges will certainly follow, long campaign, fueled by national and will run from 4-12 weeks, measuring and a hearing has already been set for interest groups, to ask the Supreme the men’s sperm counts along the way. January 23. Court to overturn Roe v. Wade.” He

6 Population Connection — March 2019 This will not be the final trial before California remains the most popu- United States Alone in approval, even if the results are positive, lous state, at 39,557,045 people, but Opposing UN Resolution but it’s a necessary step toward that goal. its numeric growth trailed Texas and At the 55th plenary meeting of the U.S. Supreme Court Refuses Florida by a large margin. UN General Assembly in December, to Hear Case Against the United States was alone in voting Planned Parenthood The country’s natural increase was against a nonbinding resolution on the 1.04 million (3,855,500 births minus “Intensification of efforts to prevent and In December, in a win for Planned 2,814,013 deaths). Immigration added eliminate all forms of violence against Parenthood, the U.S. Supreme Court 978,826 people to the population. women and girls: sexual harassment.” refused to consider a case challenging the Ohio Joins West Virginia The rest of the attending countries either decisions of five lower courts. The lower and Mississippi in Banning voted yes (130) or abstained from voting courts blocked Kansas and Louisiana Safest Second Trimester (31). Countries that voted yes included from refusing to allow Medicaid patients Abortion Procedure Afghanistan, Congo, Myanmar, North to challenge laws that prohibit reim- Korea, Saudi Arabia, South Sudan, and bursements to Planned Parenthood for Former Ohio Gov. John Kasich signed Yemen. health services they receive. a bill in December that banned the safest and most common second trimester In another vote that same day, on “Child, Only three justices were in favor of abortion procedure, dilation and evacu- early, and forced marriage,” the United accepting the case, but four justices are ation (D&E). Physicians can be charged States was one of two countries to vote required to take on any given lawsuit. with a fourth degree felony if they per- no. The other country was Nauru, a Among those who did not support hear- form such an abortion for any reason small Pacific island nation that serves ing the case was newly-confirmed Justice other than to save a woman’s life. as a detention camp for refugees and Brett Kavanaugh. migrants to Australia. In that vote, 134 2018 Saw Lowest U.S. The new law, in effect, bans abortion countries voted yes and 32 abstained Population Growth Rate in after the first trimester. That is the typical from voting. Eight Decades cutoff for vacuum aspiration abortions — after that point, dilation and evacuation References to sexual and reproductive The U.S. Census Bureau released its is the safest method. In 2017, 14 percent health in both resolutions raised con- 2018 population estimates in December of abortions in Ohio were obtained after cerns among American delegates that for the year that spanned July 1, 2017, 12 weeks of pregnancy. voting yes could be interpreted as sup- to July 1, 2018. The country’s population porting or promoting abortion. grew by 0.6 percent during that period, At the same time, former Gov. Kasich with wide variations by state. vetoed a “heartbeat bill,” which would ban abortion as early as six weeks, because Nevada and Idaho grew the fastest, both he feared an expensive lawsuit due to its at 2.1 percent. Nine states experienced obvious unconstitutionality. Gov. Mike These news clips were current as of January population decline: New York, Illinois, DeWine, sworn in on January 14, has 22, our print deadline. For the latest news West Virginia, Louisiana, Hawaii, said he would sign a heartbeat bill. If the on these and other items, please visit Mississippi, Alaska, Connecticut, and new legislature passes a new version of popconnect.org/population-news/. Wyoming (in order, by largest decline). such a bill, he will have that opportunity. – Marian Starkey www.popconnect.org March 2019 — Population Connection 7 Paul Lampert Donald J. & Sylvia Nevins Milton H. & Jeanne W. Saier Benjamin Wagner Jim Lampl Paul & Antje Newhagen Kevin M. & Susan Salisbury Arthur Wahl Brian Larson Rebecca Newland Carole S. Salman Brooke Walker Arthur R. Lash John K. Newlin Albert Sanders William Warburton Recognizing Donors for Their Generous Mary Laug Roger C. Newman Robert B. Sargent Larry Warren William C. Lawrence III & David & Susanne Newswanger Richard Schablowsky Carol Weale Contributions of $1,000 or More a Year Emmy Lawrence David R. Nichols Michael Scher Denis & Barbara Webb Kenneth L. & Priscilla W. Laws Michael Niebling Henry S. Scherer Jr. Susan Weber Anna Logan & Thomas Lawson Steven Nierlich & Tienne Lee Robert & Elizabeth Schlechter Michael A. Weissman & William J. Layton & Nuria Rodriguez Karen Nixon & Clark Searle Ray & Leola Schreurs Amanda Mardon We are deeply grateful to members of Population Connection’s 2018 President’s Circle. Thank you for your Edward & Kathryn Lee Robert Z. & Nita Norman Allan L. Schuehle Richard Wertz David Lehnherr Jennifer & Tim O’Connell Leanne L. Seeger Mark Westin generous support of our mission to stabilize global population! If you don’t see your name and believe you should Amy Lemieux William F. O’Connor Peter Seidel Kevin J. Whaley have been recognized as a member of the 2018 President’s Circle, please let us know. Contact Jennifer Lynaugh at Mark Lemkin Leslie O’Loughlin Richard Shanteau Katherine F. Wheeler [email protected]. Donald W. Leonard Lorrie Odom Timothy C. Sherck Peter Wheeler & Elizabeth Munro Dorothy & Andy Leong Kurt Oetiker Pamela Shillam Thomas & Valerie Wheeler Lois J. Levine William A. Oettmeier James M. Shultz Donald H. Whitebread & Individuals Rosemarie Carbino Elaine J. Felde John W. Hering Chun Liew George R. Oleyer Nancy M. Shurtleff Nancy C. Unger E. Curtis & Eva Lou B. Aanenson Jerry Carle Celia A. Felsher Richard & Beverly Rae Hermsen James & Susan Lindsay Roman Oliynyk & Maureen Hackett Linda W. Siecke Wayne G. Whitmore Brian F. Adams Charles Carpenter Jr. Norborn M. L. Felton Louis J. Herskowitz Arthur D. Lipson & Rochelle S. Kaplan George W. Orr Emily Slowinski Rankin A. Whittington Robert & Kerstin Adams Catherine L. Carter Dennis Ferguson Jerry M. Herst & Julie Dorman Sherri L. Little Charles Owen Cole Smith Catherine Wiehe Audra Adelberger Dianne M. Centa Rodney Ferguson Nancy S. Heymann Joanna London Anthony J. Pasquarello Francis Smith Jr. Jeffrey Wilde & Marta Wilde Bob W. Allen Wallace H. Champeny Gael Fitzmaurice William W. Hildreth Michael Louden Neela Patel David R. Snoeyenbos & Alan K. Wilkinson Mariette Allen Jonathan Claassen Frank Foulkes Dale F. Hillard Roger S. Lowen Joseph D. Perry Elizabeth Jeffery Carol Wills Edward Alpern David D. & Susan B. Clark Cameron & Diane Fowler Arthur R. Hilsinger Jr. & Perry J. Luke Bob Pettapiece Laura Somerville Aletta Wilson Kristen Anchor Hilary P. Clark Charles & Charlotte Fowler Barbara J. Janson Ernest L. & Helen H. Madsen Frank A. & Judy C.M. Pezzanite Zig Sondelski Dorothy Winkey Todd M. Anderson Spencer Clevenger Kathleen Fowler Eric Hirst Doni Mae Richard Pillmore George Sonnichsen Theodore W. & Gertrude K. Winsberg Julia S. Appel Cindy Cobb Norman Fritz Jennifer Hollingshead George Maenchen Jo Lynn Pine Sha Spady Edward Witten & Chiara R. Nappi Kent P. Bach Clifford & Carolyn Colwell E. Marianne Gabel Noel H. & Patricia K. Holmgren Bernard Magnussen John G. Pitcairn Stuart & Shirley Speyer Linda Wolcott Bill Baird Janet M. Conn Leslie Gall Joyce Homan Cynthia A. Mahoney Roger K. Pitman Morton & Jo Ellen Spitz Joan Wolstenholme Ford Ballantyne III James L. & Pauletta A. Copenheaver Susan Galvin Ellen Hooker Louise Maison Joseph G. Pittman Mary G. Sprague Felis Wood Mary Barkworth George M. Covington Janet P. Gardiner Lee R. Hougen Jack & Pat Markley Wendy Pollak Cyrus W. & Joanne Spurlino Gregory Wright & Christina Coolidge Jill Barnes Sarah Cowels Doering Pamela Garrison Catherine W. Houghton William & JoJean Marks Stuart E. Porteous Joyce Stahmann John Anthony Wright Kitty Barr Phoebe Cowles Michael S. Gendler John Houston & Katherine Read George & Sheila Marshall Ken Powell Fred Stanback Jr. & Alice Stanback S. Paul Wright Robert J. & Karen E. Bartelt Walter Crager Don C. Gentry Robert Huston Wayne Martinson Alfredo & Katherine Prelat Jean C. Stanfield Caryn Wunderlich Thomas A. & Mary L. Bartlett Tom Curran Paul L. & Barbara Gerhardt John Ide David T. Massey Martin Prince David Starr Georgiana Yap Marie A. Barton Grace A. Curry Anthony C. & Laurel Wroten Gilbert Paula K. Jackson Christopher & Catherine Mathews Warren Pruess Frank & Penny Starr Herman Zimmerman Ralph L. Bass Jr. Christine Curtis Sarah L. Gilbert & Carl E. Wieman Gary C. & Martha E. Jacobson T. D. Mathewson Cory Pulfrey Norton Starr John F. & H. Elizabeth Bednarski Charles Dahl Joan S. Gildin Robert H. Janes Arthur A. Mathiasen Donald & Alice Pulver William P. & Diane Steen Organizations Edward J. & Cynthia F. Behrman Richard Daly Duff G. Gillespie Jerry & Audrey Jedlicka Clark Maxfield Vivian Pyle H. Paul Steiger Jr. Anna Paulina Foundation David J. Benefiel Allan L. & Kendra Daniel John B. Gilpin C. Bradford Jeffries Rick & Linda Maxson Jerry Radinoff & Paula Siegel John Steinberg & Jill Pliskin Armin & Esther Hirsch Foundation Elodie Bentley Gene L. & Linda Daniels John Giurgevich Muirl R. & Joyce Johnstone Nancy C. Maze Joelle Raichle Bruce & Julie Steiner C. F. Peters Corporation Robert Berg & Carol Emerson Janet K. Davies David & Alena Goeddel Evan Jones Richard McCabe Judith E. Randal Tara M. Stevens CCS Family Fund Eleanor & Richard Berry Eugene L. Davis Rolf & Julie Anne Goetze Gifford T. & Mary E. Jones Charles McChesney Leonard Rappe Frances W. Stevenson Doris J. Foster Foundation Fred A. Berry Ed Dawson Vimal Goyle Kenneth Jones Gary W. McCormick Gerd F. Rauter K. M. Stevenson EcoTrust Jeanne Berwind Steve De Maeyer Elmer Leroy & Linda R. Grable Henri Pell Junod Jr. Michael McGee Rebecca Rawls Chuck Stout Erik E. & Edith H. Bergstrom Foundation Leslie & William Biggs Pierce Delahunt Thomas & Elizabeth Gratzek Eugene Kapaloski Patricia McQuiddy Ralph A. & Arlene F. Reed Mary Lee Strebl Gibson Family Foundation Diane Bigler Linda DeLap Julia A. Gregory Norman M. & Audrey Kaplan Renate McVittie George N. Reeke Lucy B. Stroock Hitz Foundation Roger W. & Edith R. Binkley Edward E. DeMartini Richard A. Gruen Paul Kaplan Peter Mele Thomas Reifsnyder John R. Stuelpnagel Karras Clark Family Trust Norbert W. & Inger A. Bischofberger Jeffrey Dennis Lee Gunther-Mohr Sally B. Kaplan Alan & Janis Menken Paul Reilly N.D. Catherine Sullivan Lautman, Maska, Neill & Company R.M. Bishop Robert E. Detjen Carol D. Guze Richard & Diana Kasper Friedrike Merck Glenn & Joyce Reynolds Sandra Sullivan McBride Family & Aspen Business James Blankenship Paul C. Deutsch Jason Gwinn Dennis G. & Joanne Keith John Mesching Ann F. Rhoads Edwin & Dorothy Sved Center Foundation Lawrence Blaskopf Elzbet Diaz De Leon & Joe Connett Brad Haack Vicky & Grant Kemp Jeff Messerschmidt Dwayne Rice Bill Swanson McCullough Foundation Joseph Blum Evelyn H. & Earl Dolven Elaine G. Hadden Susan M. Kennedy Dennis L. Meyer Arthur & Jane Riggs Thomas A. & Doletha Szebenyi Michael and Ina Korek Foundation David N. Bogart Julian & Katharine Donahue Deborah Halliday Roger & Dolores Kiel Rosalie Migas Susan E. Rittenhouse Philip Tatar Milligan Family Foundation Carolee C. Bol William S. Donnell Sheila Hannah Graydon C. Kingsland Christopher Miller Deborah Roach Brian Tenney Nina Abrams Fund John Borland R. H. Downes Hunter G. Hannum Terry Kitson & Paula Sherman Lincoln C. & JoAnne P. Miller Marsha Roberson Eudora Tharp Pack Foundation Pirkko H. & Bradford Borland John DuBois Roberta Hardacre Thomas Kleewein Frederick Millhiser Rob Robinson Peter R. Thomas Ranae DeSantis Foundation Norma Bradfish Nancy H. & Dick Eales Virginia Hardy Louis Kohler Carolyn Minskoff Larry & Alice Rodgers Victor J. & Lizbeth K. Thomas Ruach Foundation Ellen L. Bradley Colleen Eden Glen A. Harris Jr. & Charlotte Harris Paul V. Konka Russell Moffett William & Ann Roha Kay Thornton Ruth H. Brown Foundation Kim Bradley Paul & Anne H. Ehrlich Jessie M. Harris Hunt Kooiker & Linda Whinnery Jean & Kyra Montagu George F. Rohrmann Paul Torrence Sarah Beth Coyote Foundation Janice L. Brannon Jessie C. Eisel Kriss E. Hart Melodee Kornacker Dian Moore Barbara Rosen Don M. Triplehorn The Cole and Mislinski Family Christopher Brown & Donald & Janice C. Elliott Van & Elizabeth Hawn James Krasno Simona Morris William & Sandra Rosen Mark Trueblood The Gladys & Ralph Lazarus Foundation Susan Urquhart-Brown Thomas Emmons Eileen Heaser Karl E. & Mary Ann Krause Sandra J. Moss Paul W. Rosenberger Ariana Tuggle The Laney Thornton Foundation John E. Brown Herb Engel Charles R. Hedberg Marion Krause Denny Mullen Steven & Maren Ross Rosalie Tupper The Louis and Harold Price Foundation Shirley M. Brown Christopher Ennis Robert & Rosemary E. Heil George Krumme Edward S. Munyak Arnold Rowe Theodore A. Tyler The Moses Feldman Family Foundation Judith M. Buechner Don & Nancy Erman Larry Henderson Matthew & Kimberly Krummel Robert & Anna C. Murphy Donald Royer Jonathan Ungar The Paul H. Johanson Fund Lois Bueler Nancy M. Escoffier Donald H. Henley Bette Kulp Jan Musial Beverly A. Rubin George R. Vacek & Jessica Saxton The Prentice Foundation Charles & Judith Burch John F. Estes III Dennis J. & Jane Henner Stephen Kunkel John & Shirley Nash Claudia Ruchar Gloria D. Valdespino The Robert J. Bauer Family Foundation John & Mary G. Burkhart Thomas W. & Sarah Faulkner Theodore W. & Margie Henning Peter Kunstadter Sacheen Nathan K. C. Ruesink Diana Valois The Sheldon & Audrey Katz Foundation Trey & Lisa Calfee James Feit Donald E. Henninger George & Elisabeth Kurz Jeffrey Nelson Anne Ruffino Dave & Christine Vernier The Suwinski Family Foundation Michele Calos Betty N. Felbeck Stanley Henshaw Max G. Lagally Kathy & Alvin Neumann John J. Ryan & Margaret Silliker David Von Seggern William H. Harris Foundation

8 Population Connection — March 2019 Paul Lampert Donald J. & Sylvia Nevins Milton H. & Jeanne W. Saier Benjamin Wagner Jim Lampl Paul & Antje Newhagen Kevin M. & Susan Salisbury Arthur Wahl Brian Larson Rebecca Newland Carole S. Salman Brooke Walker Arthur R. Lash John K. Newlin Albert Sanders William Warburton Recognizing Donors for Their Generous Mary Laug Roger C. Newman Robert B. Sargent Larry Warren William C. Lawrence III & David & Susanne Newswanger Richard Schablowsky Carol Weale Contributions of $1,000 or More a Year Emmy Lawrence David R. Nichols Michael Scher Denis & Barbara Webb Kenneth L. & Priscilla W. Laws Michael Niebling Henry S. Scherer Jr. Susan Weber Anna Logan & Thomas Lawson Steven Nierlich & Tienne Lee Robert & Elizabeth Schlechter Michael A. Weissman & William J. Layton & Nuria Rodriguez Karen Nixon & Clark Searle Ray & Leola Schreurs Amanda Mardon We are deeply grateful to members of Population Connection’s 2018 President’s Circle. Thank you for your Edward & Kathryn Lee Robert Z. & Nita Norman Allan L. Schuehle Richard Wertz David Lehnherr Jennifer & Tim O’Connell Leanne L. Seeger Mark Westin generous support of our mission to stabilize global population! If you don’t see your name and believe you should Amy Lemieux William F. O’Connor Peter Seidel Kevin J. Whaley have been recognized as a member of the 2018 President’s Circle, please let us know. Contact Jennifer Lynaugh at Mark Lemkin Leslie O’Loughlin Richard Shanteau Katherine F. Wheeler [email protected]. Donald W. Leonard Lorrie Odom Timothy C. Sherck Peter Wheeler & Elizabeth Munro Dorothy & Andy Leong Kurt Oetiker Pamela Shillam Thomas & Valerie Wheeler Lois J. Levine William A. Oettmeier James M. Shultz Donald H. Whitebread & Individuals Rosemarie Carbino Elaine J. Felde John W. Hering Chun Liew George R. Oleyer Nancy M. Shurtleff Nancy C. Unger E. Curtis & Eva Lou B. Aanenson Jerry Carle Celia A. Felsher Richard & Beverly Rae Hermsen James & Susan Lindsay Roman Oliynyk & Maureen Hackett Linda W. Siecke Wayne G. Whitmore Brian F. Adams Charles Carpenter Jr. Norborn M. L. Felton Louis J. Herskowitz Arthur D. Lipson & Rochelle S. Kaplan George W. Orr Emily Slowinski Rankin A. Whittington Robert & Kerstin Adams Catherine L. Carter Dennis Ferguson Jerry M. Herst & Julie Dorman Sherri L. Little Charles Owen Cole Smith Catherine Wiehe Audra Adelberger Dianne M. Centa Rodney Ferguson Nancy S. Heymann Joanna London Anthony J. Pasquarello Francis Smith Jr. Jeffrey Wilde & Marta Wilde Bob W. Allen Wallace H. Champeny Gael Fitzmaurice William W. Hildreth Michael Louden Neela Patel David R. Snoeyenbos & Alan K. Wilkinson Mariette Allen Jonathan Claassen Frank Foulkes Dale F. Hillard Roger S. Lowen Joseph D. Perry Elizabeth Jeffery Carol Wills Edward Alpern David D. & Susan B. Clark Cameron & Diane Fowler Arthur R. Hilsinger Jr. & Perry J. Luke Bob Pettapiece Laura Somerville Aletta Wilson Kristen Anchor Hilary P. Clark Charles & Charlotte Fowler Barbara J. Janson Ernest L. & Helen H. Madsen Frank A. & Judy C.M. Pezzanite Zig Sondelski Dorothy Winkey Todd M. Anderson Spencer Clevenger Kathleen Fowler Eric Hirst Doni Mae Richard Pillmore George Sonnichsen Theodore W. & Gertrude K. Winsberg Julia S. Appel Cindy Cobb Norman Fritz Jennifer Hollingshead George Maenchen Jo Lynn Pine Sha Spady Edward Witten & Chiara R. Nappi Kent P. Bach Clifford & Carolyn Colwell E. Marianne Gabel Noel H. & Patricia K. Holmgren Bernard Magnussen John G. Pitcairn Stuart & Shirley Speyer Linda Wolcott Bill Baird Janet M. Conn Leslie Gall Joyce Homan Cynthia A. Mahoney Roger K. Pitman Morton & Jo Ellen Spitz Joan Wolstenholme Ford Ballantyne III James L. & Pauletta A. Copenheaver Susan Galvin Ellen Hooker Louise Maison Joseph G. Pittman Mary G. Sprague Felis Wood Mary Barkworth George M. Covington Janet P. Gardiner Lee R. Hougen Jack & Pat Markley Wendy Pollak Cyrus W. & Joanne Spurlino Gregory Wright & Christina Coolidge Jill Barnes Sarah Cowels Doering Pamela Garrison Catherine W. Houghton William & JoJean Marks Stuart E. Porteous Joyce Stahmann John Anthony Wright Kitty Barr Phoebe Cowles Michael S. Gendler John Houston & Katherine Read George & Sheila Marshall Ken Powell Fred Stanback Jr. & Alice Stanback S. Paul Wright Robert J. & Karen E. Bartelt Walter Crager Don C. Gentry Robert Huston Wayne Martinson Alfredo & Katherine Prelat Jean C. Stanfield Caryn Wunderlich Thomas A. & Mary L. Bartlett Tom Curran Paul L. & Barbara Gerhardt John Ide David T. Massey Martin Prince David Starr Georgiana Yap Marie A. Barton Grace A. Curry Anthony C. & Laurel Wroten Gilbert Paula K. Jackson Christopher & Catherine Mathews Warren Pruess Frank & Penny Starr Herman Zimmerman Ralph L. Bass Jr. Christine Curtis Sarah L. Gilbert & Carl E. Wieman Gary C. & Martha E. Jacobson T. D. Mathewson Cory Pulfrey Norton Starr John F. & H. Elizabeth Bednarski Charles Dahl Joan S. Gildin Robert H. Janes Arthur A. Mathiasen Donald & Alice Pulver William P. & Diane Steen Organizations Edward J. & Cynthia F. Behrman Richard Daly Duff G. Gillespie Jerry & Audrey Jedlicka Clark Maxfield Vivian Pyle H. Paul Steiger Jr. Anna Paulina Foundation David J. Benefiel Allan L. & Kendra Daniel John B. Gilpin C. Bradford Jeffries Rick & Linda Maxson Jerry Radinoff & Paula Siegel John Steinberg & Jill Pliskin Armin & Esther Hirsch Foundation Elodie Bentley Gene L. & Linda Daniels John Giurgevich Muirl R. & Joyce Johnstone Nancy C. Maze Joelle Raichle Bruce & Julie Steiner C. F. Peters Corporation Robert Berg & Carol Emerson Janet K. Davies David & Alena Goeddel Evan Jones Richard McCabe Judith E. Randal Tara M. Stevens CCS Family Fund Eleanor & Richard Berry Eugene L. Davis Rolf & Julie Anne Goetze Gifford T. & Mary E. Jones Charles McChesney Leonard Rappe Frances W. Stevenson Doris J. Foster Foundation Fred A. Berry Ed Dawson Vimal Goyle Kenneth Jones Gary W. McCormick Gerd F. Rauter K. M. Stevenson EcoTrust Jeanne Berwind Steve De Maeyer Elmer Leroy & Linda R. Grable Henri Pell Junod Jr. Michael McGee Rebecca Rawls Chuck Stout Erik E. & Edith H. Bergstrom Foundation Leslie & William Biggs Pierce Delahunt Thomas & Elizabeth Gratzek Eugene Kapaloski Patricia McQuiddy Ralph A. & Arlene F. Reed Mary Lee Strebl Gibson Family Foundation Diane Bigler Linda DeLap Julia A. Gregory Norman M. & Audrey Kaplan Renate McVittie George N. Reeke Lucy B. Stroock Hitz Foundation Roger W. & Edith R. Binkley Edward E. DeMartini Richard A. Gruen Paul Kaplan Peter Mele Thomas Reifsnyder John R. Stuelpnagel Karras Clark Family Trust Norbert W. & Inger A. Bischofberger Jeffrey Dennis Lee Gunther-Mohr Sally B. Kaplan Alan & Janis Menken Paul Reilly N.D. Catherine Sullivan Lautman, Maska, Neill & Company R.M. Bishop Robert E. Detjen Carol D. Guze Richard & Diana Kasper Friedrike Merck Glenn & Joyce Reynolds Sandra Sullivan McBride Family & Aspen Business James Blankenship Paul C. Deutsch Jason Gwinn Dennis G. & Joanne Keith John Mesching Ann F. Rhoads Edwin & Dorothy Sved Center Foundation Lawrence Blaskopf Elzbet Diaz De Leon & Joe Connett Brad Haack Vicky & Grant Kemp Jeff Messerschmidt Dwayne Rice Bill Swanson McCullough Foundation Joseph Blum Evelyn H. & Earl Dolven Elaine G. Hadden Susan M. Kennedy Dennis L. Meyer Arthur & Jane Riggs Thomas A. & Doletha Szebenyi Michael and Ina Korek Foundation David N. Bogart Julian & Katharine Donahue Deborah Halliday Roger & Dolores Kiel Rosalie Migas Susan E. Rittenhouse Philip Tatar Milligan Family Foundation Carolee C. Bol William S. Donnell Sheila Hannah Graydon C. Kingsland Christopher Miller Deborah Roach Brian Tenney Nina Abrams Fund John Borland R. H. Downes Hunter G. Hannum Terry Kitson & Paula Sherman Lincoln C. & JoAnne P. Miller Marsha Roberson Eudora Tharp Pack Foundation Pirkko H. & Bradford Borland John DuBois Roberta Hardacre Thomas Kleewein Frederick Millhiser Rob Robinson Peter R. Thomas Ranae DeSantis Foundation Norma Bradfish Nancy H. & Dick Eales Virginia Hardy Louis Kohler Carolyn Minskoff Larry & Alice Rodgers Victor J. & Lizbeth K. Thomas Ruach Foundation Ellen L. Bradley Colleen Eden Glen A. Harris Jr. & Charlotte Harris Paul V. Konka Russell Moffett William & Ann Roha Kay Thornton Ruth H. Brown Foundation Kim Bradley Paul & Anne H. Ehrlich Jessie M. Harris Hunt Kooiker & Linda Whinnery Jean & Kyra Montagu George F. Rohrmann Paul Torrence Sarah Beth Coyote Foundation Janice L. Brannon Jessie C. Eisel Kriss E. Hart Melodee Kornacker Dian Moore Barbara Rosen Don M. Triplehorn The Cole and Mislinski Family Christopher Brown & Donald & Janice C. Elliott Van & Elizabeth Hawn James Krasno Simona Morris William & Sandra Rosen Mark Trueblood The Gladys & Ralph Lazarus Foundation Susan Urquhart-Brown Thomas Emmons Eileen Heaser Karl E. & Mary Ann Krause Sandra J. Moss Paul W. Rosenberger Ariana Tuggle The Laney Thornton Foundation John E. Brown Herb Engel Charles R. Hedberg Marion Krause Denny Mullen Steven & Maren Ross Rosalie Tupper The Louis and Harold Price Foundation Shirley M. Brown Christopher Ennis Robert & Rosemary E. Heil George Krumme Edward S. Munyak Arnold Rowe Theodore A. Tyler The Moses Feldman Family Foundation Judith M. Buechner Don & Nancy Erman Larry Henderson Matthew & Kimberly Krummel Robert & Anna C. Murphy Donald Royer Jonathan Ungar The Paul H. Johanson Fund Lois Bueler Nancy M. Escoffier Donald H. Henley Bette Kulp Jan Musial Beverly A. Rubin George R. Vacek & Jessica Saxton The Prentice Foundation Charles & Judith Burch John F. Estes III Dennis J. & Jane Henner Stephen Kunkel John & Shirley Nash Claudia Ruchar Gloria D. Valdespino The Robert J. Bauer Family Foundation John & Mary G. Burkhart Thomas W. & Sarah Faulkner Theodore W. & Margie Henning Peter Kunstadter Sacheen Nathan K. C. Ruesink Diana Valois The Sheldon & Audrey Katz Foundation Trey & Lisa Calfee James Feit Donald E. Henninger George & Elisabeth Kurz Jeffrey Nelson Anne Ruffino Dave & Christine Vernier The Suwinski Family Foundation Michele Calos Betty N. Felbeck Stanley Henshaw Max G. Lagally Kathy & Alvin Neumann John J. Ryan & Margaret Silliker David Von Seggern William H. Harris Foundation

www.popconnect.org March 2019 — Population Connection 9 Population Connection at the 2018 International Conference on Family Planning in Kigali, Rwanda By Marian Starkey, Editor

wenty-five years ago, Rwandans President Kagame has frequently been living below the poverty line has gone experienced the bloodiest and accused of running an autocracy, and from 57 percent in 2006 to 39 percent most “efficient” genocide since his administration has certainly been in 2015. Progress in gender equality Hitler’s Holocaust. Upwards of a implicated in some very shady dealings is impressive as well, especially in the T million people (estimates range — including amending the constitution context of political representation. In from 800,000 – 1 million) were killed so he could run for a third presidential Rwanda, women hold 64 percent of par- over the course of a hundred horrific term in an election he won with a suspi- liamentary seats, 42 percent of cabinet days in the spring of 1994, wiping out cious 99 percent of the vote. He has been positions, and 40 percent of the justice entire families, decimating communities, accused of jailing and even assassinating seats on the Supreme Court. and trashing the country’s economy and journalists who are critical of his rule, tenuous political stability. and smearing and imprisoning political Another area where Rwanda has made opponents and their supporters. progress is sexual and reproductive Since the ceasefire, Rwanda has been health. The total fertility rate is estimated under the command of Paul Kagame. It takes a bit of intellectual compart- at 4.2 births per woman, down from 6.2 From 1994-2000, he was the Vice mentalization for me to say this, but just before the genocide. Modern con- President and Minister of Defense — there’s no denying that Kagame has traceptive prevalence is at 48 percent, up the de facto leader of the country. In done many positive things as well. The from 13 percent in 1992. These achieve- 2000, Kagame became President — a Rwandan economy has been growing at ments, even more impressive in the role he still occupies nearly 20 years later. 6-8 percent a year since 2003, inflation is context of such unimaginable national in the single digits, and the population trauma, made Rwanda a fitting host

10 Population Connection — March 2019 Clockwise from above: Lindsay Apperson, Hannah Evans, Marian Starkey, Stacie Murphy, and Lauren Salmiery at the Population Connection exhibit booth at ICFP in Kigali, Rwanda | Hauwa Shekarau, Country Director of Ipas Nigeria, poses with our social media photo frame at our exhibit booth | Irene Siaw, Youth Action Movement Coordinator at Planned Parenthood Association of Ghana

for the 5th International Conference provocative quotes from two of our sister People tittered over our blatant disdain on Family Planning (ICFP). Held organization’s field organizers were great for Donald Trump, and wanted to know November 12-15, 2018, the ICFP drew conversation starters. how he got elected and why Americans nearly 4,000 people — health providers, support his cruel policies. Upon reading “For the safety and welfare of advocates, policymakers, funders, and the aforementioned quotes and hearing women, girls, and people across youth activists — from all over the world the world, we must demand the about our organization’s opposition to to the newly constructed, state-of-the- immediate repeal of Trump’s the Global Gag Rule, many conference art Kigali Convention Center. Global Gag Rule and end the dis- attendees told us about their own health graceful attacks on women here programs losing U.S. funding due to and around the world.” Among those thousands of attendees their refusal to comply with it. were five Population Connection staff Amy McCall We exchanged business cards with doz- members. We hosted an exhibit booth New Hampshire organizer ens of people who work for programs on that gave us a home base and an easy “I don’t believe that anyone should the ground, and our field team is follow- way to make connections with confer- have a say over what I do with ing up with many of them about doing ence participants who stopped by to talk my body and I don’t believe events together and sharing their stories with us about our work. Many people Donald Trump should have a say over what women halfway across with our American grassroots activists. were drawn to our booth design, created the world do with their bodies.” by Mali Welch, who also designs our More on that in a future Field and magazine’s Pop Facts feature. The dark Brittany MacPherson Outreach column! blue walls were eye-catching, and the Arizona organizer www.popconnect.org March 2019 — Population Connection 11 Rwanda’s Community Health Workers: Meeting People Where They Are By Lindsay Apperson, Senior Field Coordinator

n the 25 years since Rwanda’s genocide, before, during, and after the genocide, contraception and breaking down the the country’s government has made life expectancy hovered around 30 years). stigma against contraceptive use. expanding access to reproductive health care a core component of its To explain Rwanda’s dramatic improve- Today, each village of approximately Idevelopment strategy, and Rwanda ments, many point to the country’s 100-150 households elects two women has consequently experienced striking network of community health workers and one man who cater to the health improvements in health outcomes. From (CHWs) and mobile outreach programs needs of their communities. These 2000 to 2015, modern contraceptive to reach the most isolated rural people. CHWs counsel, treat, and provide refer- prevalence among married women rose rals to their peers on a broad range of from 5.7 to 47.5 percent, and the fertility First implemented in 1995, the Rwandan health interventions, including modern rate decreased from 5.8 to 4.2 births per government crafted its CHW program contraception, nutrition services, HIV woman. In addition, maternal mortality to provide local community members and infectious disease prevention, inte- dropped by 84 percent, from 1,558 to with the training and tools necessary grated community case management, 253 maternal deaths per 100,000 live to educate their peers on crucial repro- and maternal and child health. births; infant mortality decreased by 64 ductive health topics. By 2005, Rwanda percent, from 117 to 42 infant deaths per had over 45,000 CHWs working within CHWs work in tandem with over 500 100,000 live births; and life expectancy at communities, with much of their work health centers in hard-to-reach com- birth increased by nearly 20 years, from focused on providing evidence-based munities across Rwanda. The health 48 to 67 (during the years immediately information about modern forms of centers provide the same range of services as CHWs, as well as consultation

12 Population Connection — March 2019 Clockwise from above: Esther is a community health worker whose health center hub is Rwamagana. | Rwamagana’s family planning register and a sampling of methods offered. | Rwamagana health center reproductive health nurse, also named Esther.

with nurses, hospitalization, pharmacy providers on gender-based violence care, by U.S. policies that threaten the reliabil- services, HIV testing and treatment, and and 156 new CHWs on community- ity of development aid. gender-based violence care. based family planning provision. However, the Rwamagana Health Participants of the 2018 International Of course, there is still more work to Center’s staff and CHWs working Conference on Family Planning (ICFP) be done. While the country has made throughout the region clearly demon- had the opportunity to visit one of these major strides in increasing access to strate that Rwanda’s innovative approach health centers in Rwamagana, a dis- family planning, Rwanda’s adolescent of integrating comprehensive reproduc- trict about 30 miles east of Kigali, and pregnancy rate increased slightly, from tive health services into its development to speak with health center staff and 6.1 percent to 7.3 percent in recent strategy is essential to ensuring the fun- CHWs working out of the facility. The years, health center staff and CHWs face damental right to a healthy life for all of Rwamagana Health Center was founded challenges in bringing men into conver- the country’s people, regardless of where in 1997 and now serves a community of sations about family planning, and nearly they live. By meeting people where they 51,592 people, spanning 52 villages in one-fifth of Rwandan women who want are and working to provide contracep- the region. to avoid pregnancy still aren’t using tion and destigmatize its use, Rwanda modern contraception. As a whole, the has set itself as an example, for both In 2018, the Rwamagana Health Center health sector faces financial instability the East African region and developing trained six providers on modern meth- that could undermine the success of the countries across the world. ods of family planning, two providers country’s many efforts, made even worse on postpartum family planning, two www.popconnect.org March 2019 — Population Connection 13 How Rwanda’s Catholic Clinics Struck a Contraception Compromise

Article and photos by Ryan Lenora Brown | Originally published by the Christian Science Monitor

Often, religion can divide when it comes to policies like contraception. But in Rwanda, both sides have found a compromise even as their faith has led them in different directions.

he Roman Catholic health center that hugs the main “That is our faith. We cannot change what we believe,” says road here announces its faith plainly. ARCHDIOCESE Mary Goretti Nyirabahutu, the nun in charge of the health OF KIGALI, reads the sign sprawled across the facade center. of the stout red brick building in this small town just Toutside Rwanda’s capital. Holographic portraits of Jesus and But now, around the corner, wedged into half of an old munici- Mary stare down from the walls of every exam and consultation pal office at the end of a long dirt road, a tiny government health room, and nuns wander the corridors in full gray habits. center whispers an alternative. Its door is unmarked except for a tiny sign above the doorway reading, “Kuboneza Urubyaro.” For decades, if you needed health care in this town, this was your Family Planning. option. And that included women looking for birth control — most forms of which the Catholic Church forbids.

14 Population Connection — March 2019 Left: Sister Mary Goretti Nyirabahutu runs the Catholic health center in Masaka, a small town outside Rwanda’s capital, Kigali. For decades, it was the only hospital in the area. Above: A sign directs patients to the secondary health post in Masaka. Secondary health posts have been set up by the government near most of the country’s Catholic hospitals in the last decade to offer modern birth control services that they do not provide. Right: Nurse Jackie Buseruka runs the government health post situated down the road from Masaka’s Catholic hospital. Unlike that institution, her health post offers modern birth control.

“I’m also a woman of prayer,” says Jackie Buseruka, the nurse development, they knew they had to include the Catholic who runs the clinic. “But your religion must not interfere with Church, since half of Rwandans are members. Long a powerful doing what is right.” institution here, the church runs about a third of the country’s hospitals and clinics, according to the Catholic charity Caritas Battles over access to birth control and abortion are often cast — many of them in remote areas where there is no govern- as a fight between a secular left and a religious right. But in ment-run alternative. Rwanda, as in much of Africa, people on both sides of the aisle feel God is with them. Both advocates and opponents of mod- The church, meanwhile, was resolute — it wouldn’t provide arti- ern family planning frequently cite faith as their motivation. ficial birth control. That was against Rome’s doctrine.

And that has led to strikingly different ideas for how to expand But it didn’t make much sense to build new hospitals in those access to birth control to the women who need it most. areas. So the church and the government struck a deal.

When Rwanda’s government was looking for ways to increase Women who came to Catholic facilities looking for contracep- the number of women using contraception a decade ago as tives would be told their options — all their options — and part of a broader push to improve health care and promote then pointed down the road to the new mini “health posts” the www.popconnect.org March 2019 — Population Connection 15 government was setting up in the shadow of every Catholic “I cannot be limited by my faith when it comes to family plan- hospital. Tiny, bare-bones operations, they had a single purpose: ning,” says Adrian Hakorimana, a herdsman in Masaka. “The Volunteer with to give out birth control. Today, there are 88 of these, tethered most important thing to me as a Catholic is to have a family to about 80 percent of the Catholic hospitals and clinics in the that is a size I can take care of.” country. “It’s a Calling” Population Connection! “The way we see it, people are responsible for their own health Inside Ms. Buseruka’s dimly lit government clinic, she spreads and their own faith,” says Prince-Bosco Kanani, the director of out a menu of options for her patients. There are packets of pills Rwanda Catholic Health Services. “Our spiritual mandate is to and intrauterine devices, silver condom packets, and little vials SPREAD THE MESSAGE! let people choose.” of injectable contraceptives. “I never turn anyone who comes to this place away,” she says. “If they’re worried about religion, I tell POPULATION CONNECTION’S MEMBERSHIP Many Rwandan women have chosen modern birth control. them, God helps those who help themselves.” ENGAGEMENT TEAM is here to support your local outreach. Since 1995, the country’s fertility rate has fallen from six chil- * If you’re a current Population Connection member, then dren per woman to under four. Two-thirds of married women Buseruka’s clinic has about 7,000 patients, from shy teenage JOIN US as we reach out across the country! We will give you and nearly one-third of women total now use contraceptives. girls to the wives of local pastors, who often send her text mes- all the tools and resources you need to inform your community sages asking if they can come by the clinic after hours, when no about the importance of global population stabilization. Difficult Conversations one will be around to see. Sex is, perhaps, not the first topic the church wants to discuss. Ways You Can Get Involved: But in Africa, more than anywhere in the world, sex and public Down the road, at the Catholic health center, Ms. Nyirabahutu • Host an informational booth at a local event. health have collided in ways that forced the church into the leads her own spirited family planning crusade — to interest conversation. couples in church-sanctioned forms of “natural family plan- • Organize a fi lm screening at your local library or ning.” She clutches a string of beads in her hand like a rosary, community center. Host an information booth “When HIV came to finish us, that’s when we realized we explaining that couples can use it to count the days of a woman’s • Request a Population Connection speaker, such as couldn’t keep sex in the dark. We had to begin speaking about cycle. Hannah Evans, our Population, Health, and Environment it in broad daylight,” says Ronald Kasyaba, the deputy executive Specialist (pictured, left), for your local group meeting. secretary at Catholic Medical Bureau in neighboring Uganda. But it’s a hard sell. She sees only about 1,000 patients regu- “And the conversation has progressed from there.” larly for such services, she says, and only couples. “If you don’t • Distribute Population Connection magazines locally. have a husband, what do you need family planning for?” she • Write a letter to the editor of your local paper. In Rwanda, as in many countries, the prevalence of Catholic says, breaking into a wide-brimmed laugh. “You have nothing • Attend a march or rally. health centers means they have been close to the HIV epi- to plan.” demic for decades. (The Vatican has estimated that it provides REACH OUT TO OUR TEAM: 25 percent of the care HIV and AIDS patients receive world- Still, she says she fully supports the government outpost down wide.) That, in turn, necessitated a tough moral reckoning the road. Email us at [email protected]. among many Catholic health officials about the need to talk Our coordinators will help you fi nd a way to get involved! loudly and clearly to parishioners about protection against sexu- “Of course they are serving more people than us [at the second- For more information or to fi nd an event near you, visit ally transmitted diseases — a subject the church had historically ary health posts]. They have more to offer,” she says. But it isn’t Invite a speaker www.popconnect.org/getinvolved. spoken about only in whispers. a competition. “Health care, for us, it’s a calling. And the most important thing is that women are healthy, that having children Yet it has been reluctant to approve of the use of condoms to is their own choice. They must be free to choose what is right prevent HIV, let alone as contraception. But Kigali is also far for them.” from Rome, and when church teachings and practical need diverge, many will quietly choose the latter. Nasra Bishumba contributed reporting to this story. Reporting for this story was also supported in part by a fellowship from the United Nations Foundation. * The UN Population Division projected in 2017 that Rwanda’s 2019 total fertility rate (TFR) would be 3.8 births per woman; the last fertility estimate, from 2015, put Rwanda’s TFR at 4.2. –Marian Starkey Attend a march Host a fi lm or rally screening 16 Population Connection — March 2019 Volunteer with Population Connection! SPREAD THE MESSAGE!

POPULATION CONNECTION’S MEMBERSHIP ENGAGEMENT TEAM is here to support your local outreach. If you’re a current Population Connection member, then JOIN US as we reach out across the country! We will give you all the tools and resources you need to inform your community about the importance of global population stabilization.

Ways You Can Get Involved: • Host an informational booth at a local event. • Organize a ﬁ lm screening at your local library or community center. Host an information booth • Request a Population Connection speaker, such as Hannah Evans, our Population, Health, and Environment Specialist (pictured, left), for your local group meeting. • Distribute Population Connection magazines locally. • Write a letter to the editor of your local paper. • Attend a march or rally.

REACH OUT TO OUR TEAM: Email us at [email protected]. Our coordinators will help you ﬁ nd a way to get involved! For more information or to ﬁ nd an event near you, visit Invite a speaker www.popconnect.org/getinvolved.

Attend a march Host a ﬁ lm or rally screening Resiliency In The Face Of Harmful Rhetoric From A Heartless Leader halfway across the world

By Lauren Salmiery, National Field Director FHOK Youth Center in Eastleigh, Nairobi March 2019 — Population Connection 19 hen Donald Trump reinstated the Global Gag Rule from organizations like Population on January 23, 2017, nurses, doctors, lab technicians, Connection. Aggrey Marita, the FHOK advocates, and, most importantly, patients all felt Kibera Medical Center Manager, does the impact. International family planning providers not allow a single patient to go unseen. were faced with a stark choice: They could keep quiet He says it’s worth it to forgo clinic Wabout abortion as an option, or they could refuse, and lose their U.S. improvements to avoid denying vulner- funding. able people service. While there used to To make matters worse, as if the original version of the Global Gag be five or six providers at the clinic, there Rule, levied previously by Reagan, Bush One, and Bush Two, wasn’t are now only two, each of whom sees bad enough, the Trump administration announced that it would 50-60 patients in a single day. expand the rule from its traditional application to family planning aid (currently $525 million) to all $8.8 billion in global health assistance. In Kenya, abortion is only allowed in This means providers working on child nutrition, malaria prevention order to protect the health or save the life of the pregnant woman. For women who and treatment, and antiretroviral (ARV) provision for HIV/AIDS find themselves with an unwanted preg- patients are all subjected to the mandate: sign, or lose funding. nancy, but don’t meet the legal criteria, an unsafe abortion may seem like the only Established in 1962, Family Health how to react to the threat of losing fund- option. Aggrey made it clear that back Options Kenya (FHOK) is one of the ing in exchange for the stifling of its free alley abortions are often more accessible longest standing providers of reproduc- speech by a government that claims to be to the Kibera community than the safe tive health services in Kenya, reaching an ally. Instead, we saw a resilient organi- abortion services offered at the FHOK diverse groups through its clinics, its out- zation fueled by the fight that lies ahead. clinics. The cost of transportation (50- reach services to remote communities, Despite the harmful policies of the U.S. 70 KSh, or 50-70 cents) to the Nairobi and its youth friendly centers. FHOK government, FHOK showed an eager- West clinic for a safe surgical abortion has provided millions of Kenyans with ness to work alongside American allies may be prohibitive, or patients may fear access to contraception, cervical cancer like Population Connection to achieve a they don’t fit the criteria for legal abor- screenings, antenatal care, HIV/AIDS collective goal: permanent repeal of the tion and will be turned away. testing, counseling, and treatment, and Global Gag Rule. general health services for decades. Mercy Atieno, a 23-year-old mother of An International Planned Parenthood Since Trump’s Gag Rule was imposed, an eight-month-old boy, Liam, came to Federation (IPPF) affiliate, FHOK has FHOK has had to close clinics and cut FHOK after an unsafe abortion left her historically refused to sign the Global back on its services in hard-to-reach septic and near death. Mercy’s boyfriend Gag Rule because its service providers communities. While in the past, many had left her when she told him she was believe that access to the full range of clients received services free of charge, pregnant — when Liam was only six reproductive health care, including abor- depending on their financial standing, months old — and her family was unable tion services, is a human right. they may now have to pay. A once free to support her having another child. consultation may now cost 100-150 KSh Feeling she had no other option, Mercy n November, on the heels of attend- ($1.00-1.50) — unaffordable for people found a quack doctor to terminate her ing the International Conference on struggling to put food on the table. pregnancy. IFamily Planning (ICFP) in Rwanda, my colleague Lindsay Apperson and I At the FHOK clinic in Kibera, the larg- Mercy was lucky, and with the post- had the opportunity to visit a few of the est slum in East Africa, the likelihood of abortion care that Aggrey provided sites where FHOK provides safe, com- a patient being unable to afford services her and some bed rest, she was able to prehensive, and client-focused services is high, but the rate of denial of services recover. Before she left, Mercy was coun- in the Nairobi area. What we witnessed is zero. Nearly all — 95 percent — of seled on family planning — something was not a community broken by the poli- the services provided at the Kibera clinic she knew little about. After learning cies of a heartless leader halfway across are free, thanks to Gag Rule mitigation about her options and what family plan- the world, or an organization torn over funds from various sources and grants ning could do to help her, Mercy chose

20 Population Connection — March 2019 Above: The pharmacy at FHOK Kibera | Left: FHOK Kibera clinic. The mural says, “Family Planning: My Family, My Choice, My Size.”

nlike the clinic in Kibera, some Nairobi area clinics have begun to Ucharge clients because they don’t have access to the same Gag Rule mitigation funds that Kibera has. When patients can’t afford fees and clinic expenses cannot be paid, facilities are forced to close. Clinics in Mombasa, previously a hub the contraceptive implant. She also both with and without children, to dis- for mobile outreach services to rural decided to take on a leadership role to cuss how important contraception is. communities; Kitengela, which served counsel other young women, and has Conversation is open, honest, and led by one of the most vulnerable communities since become a community advocate for a woman with a story all too common for on the fringe of Nairobi County; and comprehensive reproductive health care many of the people in the room. Isiola have closed. FHOK’s Director of in her Kibera neighborhood. She hosts Clinical Services, Amos Simpano, antic- weekly talks with other young women, ipates more closures in 2019. www.popconnect.org March 2019 — Population Connection 21 Above: Olivia Tuti, Lauren Salmiery, Amos Simpano, Lindsay Apperson, and Josephine Kimani pose for a photo in front of Eastleigh Youth Center Left: Aggrey Marita inside the FHOK Kibera clinic

Closing clinics also has an impact on health care. It’s a place for young people staff. Olivia Tuti, the former Medical to be themselves; to discuss intimate- Center Manager at the Kitengela clinic, partner violence in the weightlifting and her staff lost their jobs due to the gym; to share emotions and bond over reinstatement of the Global Gag Rule. pop culture in the henna salon; to talk In the short while that Olivia struggled about the changing political atmosphere to find work in the competitive Nairobi in the barbershop; and to celebrate each job market, Amos had applied for a grant other’s individuality in the photography from IPPF, which manages a Gag Rule studio. response fund that its affiliates can access. More often than not, FHOK is the only That grant was awarded to FHOK, and Through the Young People Advocating health care provider in a Kenyan com- Olivia now leads the Global Gag Rule for Health (YAH) program, youth lead- munity, and even more frequently the Mitigation Project for the program. ers are trained to facilitate discussions only provider of reproductive health care within their communities about repro- services. Patients have built generations- he FHOK Nairobi Youth Center in ductive health care, something that long relationships with providers, and the neighborhood of Eastleigh, run has helped break down cultural barri- communities trust the clinics for safe, byT Josephine Kimani, is more than just a ers. For Muslim youth leaders, many of honest, and comprehensive care. place where young people go to receive them Somali refugees, the time spent

22 Population Connection — March 2019 communicating with religious leaders which provides FHOK with medica- has paid off. As a result of these discus- tions and supplies, is having a devastating sions, sheiks and imams have given the effect on the availability of commodities. youth permission to facilitate conversations about sexual and reproductive bout an hour outside of Nairobi health with other members of their faith lies Thika, a peri-urban center with communities. anA economy based on livestock and pine- apple farming. Brian Waithaka, Medical Through the drama club, they create Center Manager of the FHOK Thika messaging calling for women’s empow- clinic, delivered a clear message as we erment and access to contraception. sat down: “We don’t turn patients away.” Through the YAH program, young While a list of service costs is available, people are advocating with county lead- clients who are unable to pull together ers about the importance of funding the funds may be given a subsidized cost, contraceptive services and encouraging or receive a cost-free service, dependent comprehensive sexuality education in on their income level. schools. That includes HIV/AIDS clients, who When we asked the young people at sometimes travel long distances to reach the youth center why family planning the clinic. Brian and his colleague Moses was important to them, we got the usual Okanda, SRH/HIV/AIDS Counselor, Top: Lauren signs the guest book at the Thika clinic while Brian Waithaka look on. Bottom: range of responses: “I’m not ready for discussed how the stigma of being HIV Moses Okanda displays an award that FHOK children,” or “I want to start a career positive is still very prominent. For many won for its provision of cervical cancer screenings. first,” or “I want to be able to space my patients, that means seeking care within births so that I can have healthy preg- their own communities is not an option. nancies.” But one young person offered Some travel the 200 kilometers from a much more grim response: “My area is Nakuru to Thika to receive their ARVs for moment — the maternity ward. The cli- not safe to be there because maybe there the month just to protect the confidenti- ents are streaming in saying, ‘You guys, are rape cases, so it’s a sense of security.” ality of their status. When clients arrive why don’t you have a maternity?’ That The idea that contraception provides a at the clinic, they are not quarantined in actually is the only thing we are missing “sense of security” in the event of sexual an HIV/AIDS specific counseling room, at the moment,” Moses explained. assault is the reality for so many young as is common at many medical facilities. women in Nairobi, in Kenya, and around At FHOK Thika, clients are seen in any linics choosing not to bend to the the world. clinic room regardless of HIV/AIDS harmful rhetoric of a president status in order to protect their privacy; Cwho is on the other side of the world During our discussion, one young this is the standard at all FHOK clinics. are champions of free speech and of a man demanded that the leadership at If the FHOK Thika clinic were to close, commitment to comprehensive health FHOK, present in the room with us, patients who rely on the confidentiality care. Service providers and program increase commodities at the youth cen- of its HIV/AIDS testing, counseling, managers like Aggrey, Amos, Olivia, ter. There are shortfalls of antibiotics and ARV provision services could lose Josephine, Brian, and Moses are saving and other medications, and sometimes access to their only trusted provider. lives through their work every single day. of contraceptives. But these stockouts Though Trump’s Global Gag Rule puts a have nothing to do with bureaucracy When asked what they would do with strain on their ability to provide care, it at FHOK, and everything to do with hypothetical additional funding, Brian doesn’t stop them. foreign assistance bureaucracy in the and Moses didn’t hesitate: more outreach United States. The Gag Rule, combined services to the remote rural communities with Trump’s refusal to fund the United in Thika, and a 24-hour maternity ward. Nations Population Fund (UNFPA), “That is the pressure we are having at the www.popconnect.org March 2019 — Population Connection 23 HOW TO GRAPPLE WITH SOARING WORLD POPULATION? AN ANSWER FROM BOTSWANA

Botswana has one of the fastest falling fertility rates. As global population expands, there are lessons to be learned.

t the end of a dusty road in the southern world and populations are soaring, Botswana has a dif- African hinterland sits a small concrete ferent story to tell. building with an orange door. It is a structure so modest and remote that it Fifty years ago, Botswanan women would have seven is hard to believe it could hold lessons children on average. Now they have fewer than three. for addressing one of the world’s biggest challenges. It’s one of the fastest falling fertility rates anywhere in the world — a dramatic decline that merits scrutiny. TheA unit is the medical hub for Gasita, a village of 2,000 people in the south of Botswana. Inside one of the The world’s population is on track to hit 8 billion in rooms, pharmaceutical supplies are neatly stashed on 2023, and almost 10 billion by 2050. Sub-Saharan shelves while a photograph of the country’s president, Africa is set to grow faster than anywhere: there were Mokgweetsi Masisi, is propped up on a counter next to 1 billion Africans in 2010, but that number will grow to a window that is ajar, letting in a warm breeze. 2.5 billion by 2050.

Outposts like these — offering family planning services, Some have warned that this growth risks “driving civi- contraception, education — have helped bring about lization over the edge,” a controversial view given that it one of the world’s most remarkable demographic shifts. is rich countries, not poor, that lead the way on consum- In a continent where fertility rates are the highest in the ing the world’s resources.

24 Population Connection — March 2019 In a continent where fertility rates are the highest in the world and populations are soaring, Botswana has a different story to tell. Article by Nicola Davis Photos by Pako Lesejane Originally published by The Guardian Supported by The Skoll Foundation

The health center in Gasita, a village of 2,000 people in the south of Botswana

www.popconnect.org March 2019 — Population Connection 25 But enabling women to control their fertility — a move and Reproductive Health Initiative, she spends her days that almost inevitably leads to them having fewer babies delving into issues around fertility and contraception. — is not just about a tussle over resources, or the environment: It brings enormous ramifications for women’s But Morroni says understanding Botswana’s dramatic health, education, and employment — with knock-on fertility decline involves teasing apart a complex web of effects for society and the economy. factors.

So what did Botswana get right? “There’s been a huge amount of change in Botswana,” she says, pointing out that since Botswana became an n a ground floor office at the University of Botswana, independent country in 1966, the landscape developed in the country’s capital of Gaborone, Dr. Chelsea quickly, with high levels of economic growth and devel- Morroni considers the issue. “Everyone is always opment of both health care infrastructure and education Iasking, ‘how did this happen?’ ” infrastructure, enabling young women to become edu- cated and have employment opportunities. An expert in international sexual and reproductive health at the Liverpool School of Tropical Medicine, “All of those things on the macro level are really impor- Morroni has lived in Botswana with her family for five tant to fertility declines anywhere in the world,” says years. As founder and director of the Botswana Sexual Morroni, whose work is part of the Botswana UPenn

Phenyo Ntoko fitting a contraceptive implant for a woman in Gasita

26 Population Connection — March 2019 Partnership: a collaboration between the Botswana sitting inside the Gasita room, the fabric around her health ministry, the University of Botswana, and the hair bright with the colors of the Botswana flag. University of Pennsylvania. A single mother, Chyna found respite from multiple But the country made more direct strides, too. “Botswana pregnancies through the work of Bofwa. also was very proactive in the early years in establishing a family planning program, so in setting up a program “I eventually got to find out about the implant from that was far-reaching in terms of its geographical reach, Bofwa — I asked for help because the pregnancies were providing access to most people in the country to a getting out of hand and, knowing myself, if it wasn’t for range of contraceptive methods,” says Morroni. the implant I would still be pregnant now,” says Chyna, speaking through an interpreter. Maternal and child health and family planning services were integrated from the outset more than 40 years ago. “I am very, very grateful. My only problem is that I have A suite of contraceptives are now available through got so many kids that I can barely take care of [them]. facilities ranging from the most rural health posts They need clothing, they need to be fed.” to urban hospitals. An NGO, the Botswana Family Welfare Association (Bofwa), works with the govern- While the health post is government run, Bofwa makes ment to reach out to even the most rural of locations a visit about once a quarter to Gasita and nine other around the country to improve access to sexual and reproductive health services, particularly among young people. Fifty years ago, There are other considerations, too. The infant mortality rate decreased from 97.1 deaths per 1,000 live births in Botswanan women 1971 to 17 in 2011, while an increasing proportion of the population living in urban settings could also play would have seven a role: Fertility rates are generally higher in rural areas. children on average. And there is another issue. “Botswana … has been very hard hit by HIV, one of the hardest hit countries in the Now they have world,” says Morroni. And as she points out, research fewer than three. It’s suggests there is an association between HIV infection and reduced fertility, although how much of a contribu- one of the fastest tion that has made to the steep fertility decline is very difficult to say. “Luckily with the advent of universal falling fertility rates access to antiretroviral therapy we are seeing a narrow- ing of the gap between fertility in HIV infected and anywhere in the uninfected people which is really, really a step in the right direction,” she says. world — a dramatic

All of which mean that women like Chyna are becom- decline that merits ing statistically rarer. “I have seven children and all the time I was bearing these seven children, there was never scrutiny. a break in between eight years,” says the 30-year-old,

www.popconnect.org March 2019 — Population Connection 27 settlements around Kanye, led by nurse and midwife high quality family planning program with reach,” she Phenyo Ntoko. These outposts are replicated across says. rural Botswana, where women are increasingly keen to embrace contraception, including the implant, which A World Bank report on Botswana’s fertility revolution sits in the upper arm and lasts for years. says myriad other factors contribute to a more mea- sured approach to family planning: the education of Their priorities are as individual as the women them- girls, encouraging women to enter in the workforce, and selves. For some it is about preventing pregnancies at an reaching individuals in their homes by means of visits by early age, for others the main goal is to space children. family welfare educators. Many women gathered at the health posts said they only want two, with many years between them to help Una Ngwenya, the chief executive of Bofwa, agrees that them raise their first child well. the family welfare educators were a key factor behind the fertility decline. But, she adds that national averages Despite the complex range of factors behind the dra- don’t tell the whole story. matic fertility decline, and the fact that different countries have different political histories and cultural “Where I work, mothers still have six kids,” she says. and social influences that make comparisons difficult, “People tell you in Botswana you have an average of Morroni believes other nations could take a leaf out of women having two kids — I ask you, where? I cannot Botswana’s book. see that.

“From my perspective it is really about having the polit- “We are one of the most unequal countries in the world ical will for the development and implementation of a — what happens here in the big villages and in the cit- ies does not necessarily happen in Lorolwane,” she adds, referring to a remote village beyond Gasita, as yet without electricity.

A member association of the International Planned Dr. Chelsea Morroni Parenthood Federation, Bofwa receives core funding in her office at the University of from the organization, as well as some government Botswana funding and contraceptive commodities and antiretroviral drugs from Botswana’s Ministry of Health and Wellness. Other partners include the Positive Action for Children Fund from private firm ViiV Healthcare.

“We have five centers,” Ngwenya says, ticking off sites around the country. “It gives me satisfaction to see a group of girls speaking very confidently about how they want to make their choices.” Ngwenya rejects the idea that contraception is being pushed on women, pointing out that communities are impatient for Bofwa to work with them. “It used to be difficult to go into a community and talk about contraception. Now they even [say], ‘hey you are taking too long, come to our community, we need you people here, now,’ ” she says.

28 Population Connection — March 2019 But Bofwa has had to close at least two centers because of Donald Trump’s reinstatement of the controversial “Ah, that was such a Global Gag Rule, which prevents U.S. federal funds going to any group that performs or even provides blow. The impact of information about abortions. the Gag Rule was so Among the Bofwa services suspended are projects specifically engaging with populations, including sex much on the clients, workers and men who have sex with men, as well as another working with vulnerable children. but also on Bofwa’s

“Ah, that was such a blow,” says Ngwenya with a sigh. reputation. It really “The impact of the Gag Rule was so much on the cli- impacted our work ents, but also on Bofwa’s reputation. It really impacted our work in a very negative manner.” in a very negative Bofwa does not provide abortions, but it does counsel manner.” women who might be seeking one — which is legal under certain conditions in Botswana — and those who have had an abortion.

Una Ngwenya at the “For me, it is rewarding to see Bofwa help one girl to Bofwa headquarters terminate a pregnancy that came from incest,” says in Gaborone Ngwenya, adding that improving understanding of when abortion is currently legal is important. “We want the community to know their rights,” she says, noting that the team sees cases of young teenagers becoming pregnant. “Our research tells us there is a lot of need here. What has happened to these kids? Could it be rape, could it be defilement?”

Nonetheless, Ngwenya is sanguine. “Bofwa is a very resilient organization; we have been here for 30 years and we will go on for a good while to come.”

www.popconnect.org March 2019 — Population Connection 29 w

ie Brand New Congress Arrives, Comes V Face to Face with Same Old Trump By Stacie Murphy, Director of Congressional Relations ashington W

The 116th Congress has already made The election results mean there is now co-pays. The Obama administration had history. a solid pro-family planning majority in previously allowed some narrow exemp- the House. The Senate remains another tions to the rule for churches and other There were a number of firsts in this story. However, with Sens. Susan Collins religious institutions, but the Trump freshman class, which was sworn in on (R-ME) and Lisa Murkowski (R-AK) administration has sought to allow any January 3. Ilhan Omar (D-MN) and maintaining their seats on the powerful entity to opt out of the requirement Rashida Tlaib (D-MI) became the Appropriations Committee, that com- based on religious or moral objections. first Muslim American women elected mittee still has a pro-family planning The preliminary injunction is not perma- to Congress. Sharice Davids (D-KS) majority. We will be watching with great nent. Rather, it delays implementation of and Deb Haaland (D-NM) are the interest as the Fiscal Year 2020 appro- the policy until the remaining lawsuits first Native American women to serve. priations process unfolds (eventually, one are settled. Davids is also the first openly LGBTQ presumes — see below). person sent to Congress by the state of Budget Impasse Leads to Kansas. Veronica Escobar (D) and Sylvia Now that the new Congress is in Record-Setting Shutdown Garcia (D) became the first Latinas to place, we expect the Global Health, At the time of our press deadline, the represent Texas. Empowerment, and Rights Act (Global United States was a month into a partial HER Act) to be reintroduced in both government shutdown. It’s a new record, Overall, a record 117 women — 102 in the House and Senate in early February. easily eclipsing the previous mark of 21 the House and 15 in the Senate — will During the 115th Congress, the bill had days set in January 1996. serve in the 116th Congress. Twenty-four 165 cosponsors in the House and 47 in of the new House members are people of the Senate. A quick recap of how we got here: color, including 13 women of color. Six states now have two female senators: Trump Rollback of Birth Back in September, Congress approved Arizona, California, Minnesota, Nevada, Control Benefit Stymied by a full-year budget package for several New Hampshire, and Washington. In Courts parts of the government, including the Arizona, Rep. Kyrsten Sinema (D) nar- The day it was set to take effect, a federal Department of Health and Human rowly defeated Rep. Martha McSally (R) judge in Pennsylvania issued a nation- Services, which oversees Title X, the for the seat of retiring Senator Jeff Flake wide preliminary injunction against nation’s family planning program for low- (R). McSally was later appointed to the Trump administration’s rollback of income people. The State Department, replace Sen. Jon Kyl (R), who had agreed the Affordable Care Act’s (ACA) birth however, which has jurisdiction over our to serve temporarily after the August control benefit. The benefit requires that international family planning programs, death of Senator John McCain. insurance plans cover all FDA approved was among the agencies that did not see methods of birth control without its Fiscal Year 2019 budget passed.

30 Population Connection — March 2019 Instead, Congress passed a Continuing Approximately 75 percent of the gov- Population Fund (UNFPA) of $32.5 Resolution (CR), extending funding for ernment was funded through the bills million — although the current Kemp- those agencies at FY 2018 levels through passed in September, but the shutdown Kasten determination barring funding early December. The expectation was is nonetheless having significant and to UNFPA means that money would be that after the November elections, the growing effects. Many national parks “reprogrammed” to other women’s health lame-duck Congress would either pass are closed, some food inspections have initiatives. the remaining full-year bills or agree to stopped, and the Internal Revenue another CR, keeping the government Service has indicated that tax filings and The new House of Representatives, open until the 116th Congress was refunds may be delayed if the shutdown however, wasted no time in signaling seated. continues. Personnel deemed “essential” where it stands on these issues, passing are required to work during the shut- a funding bill that included the Senate For a time, they appeared to be on track down, though they are not being paid. Appropriations Committee’s family to follow the first course. Believing they Affected employees include TSA and planning language — higher funding were on the verge of an agreement, leg- air-traffic control personnel, along with than had been passed by the previous islators passed a short CR extending members of the Coast Guard and some House, a repeal of the Global Gag Rule, funding through December 21, in order 13,000 FBI agents. As has happened and funding for UNFPA. to give themselves more time to finalize during previous shutdowns, government the details. Although Donald Trump had workers are expected to receive back pay Anti-family planning members imme- previously claimed he would not sign once the government reopens, though diately offered a motion to strip those any bill that did not appropriate billions most contractors will not. provisions from the bill, but, fortunately, of dollars for a wall on the United States/ it failed 199-232. Democrats Collin Mexico border, congressional leadership What does all this mean for inter- Peterson (MN) and Dan Lipinski (IL) had assurances that he would sign the national family planning programs? joined all Republican members of the package when it was ready. Right now, the shutdown means no House in voting for the motion. The new money is flowing, and many of the Senate declined to take up the measure. At the last minute, however, egged on by people who administer the programs are voices from the far right, Trump reneged furloughed. Going forward, the situation Whatever ultimately happens, we’ve all on his agreement and announced he is murkier. The bill negotiated before the been put on notice that this new House would refuse to sign the measure due shutdown maintained the status quo of Representatives is willing to fight for to its lack of funding for a border wall. for international family planning — no these priorities, and it’s a thrilling thing Legislators scrambled for a solution, but change to the Global Gag Rule, $575 to see. the government entered a partial shut- million for bilateral programs, and a down at midnight on December 22. U.S. contribution to the United Nations www.popconnect.org March 2019 — Population Connection 31 Two Years in the #Fight4HER By Lindsay Apperson, Senior Field Coordinator utreach & O ield F

ust over two years ago, we launched our #Fight4HER campaign to push back against attacks on reproductive health and rights under the Trump administration. Our grassroots volunteers across the country have maintained their unwavering Jactivism while collecting over 25,000 petitions to repeal Trump’s Global Gag Rule, activating hundreds of volunteers in communities across the country, and hosting hundreds of events to show Trump and his cronies that we will not stand by as they undermine access to reproductive health care worldwide. As we continue the fight in 2019, we reflect on all of the progress we’ve made in the #Fight4HER so far.

2017 • We launched our campaign in six states (Arizona, Colorado, New Hampshire, North Carolina, Ohio, and Pennsylvania), hiring organizers and hosting silent dem- onstrations, photo petitions, press conferences, teach-ins, and petition drops to protest Trump’s deadly Global Gag Rule.

• We hosted Capitol Hill Days 2017, drawing 333 activists from 34 states across the country to Washington, DC, for a weekend of advocacy #Fight4HER activists march on International Women’s Day 2017 at Ohio State University training and meetings with their members of Congress. administration to repeal the we learned how to be better allies Affordable Care Act. to the reproductive justice move- • We joined the Protect Our ment. Our field staff also presented Care coalition to push back • We attended the “Let’s Talk a workshop at the conference against attempts by the Trump About Sex” conference, hosted by on how activists can effectively SisterSong in New Orleans, where #Fight4HER.

32 Population Connection — March 2019 • On International Safe Abortion and Wisconsin to shame Trump • We hired organizers in Tucson, Day, we were joined by Population and then-Speaker of the House Arizona, and Charlotte, North Institute, Reproaction, Advocates Paul Ryan for their disregard for Carolina, adding to the outreach we for Youth, and Physicians for women’s health and lives. had already been doing in Phoenix Reproductive Health for a pro- and Research Triangle (Raleigh, test outside of the White House • We hosted our largest Capitol Hill Durham, and Chapel Hill). to “Make Some Noise for Safe Days ever in 2018, with nearly 350 Abortion Access.” participants from 25 states and 169 • We pushed back against the nomi- congressional districts. nation of Brett Kavanaugh to the • After gaining momentum, we Supreme Court, rallying in DC and expanded our campaign into • We launched our Summer of key states and urging senators to Nevada and Wisconsin, where two HER project in our eight cam- reject his nomination. new organizers joined our ranks. paign states, collecting nearly 8,000 petitions, engaging 52 The House now has a majority support- • We traveled around seven states fellows, recruiting 121 volunteers, ive of family planning and reproductive with Family Health Options Kenya and receiving 105 #Fight4HER health programs. On its very first day, (FHOK) Director of Clinical campaign endorsements from the House passed a government funding Services Amos Simpano, FHOK community leaders, businesses, and bill that included provisions repealing Kibera Clinic Director Melvine coalition partners. the Global Gag Rule and restoring aid Ouyo, and human rights activ- to the United Nations Population Fund ist Lisa Shannon to share stories • We hosted Summer of HER (UNFPA). Rep. Nita Lowey and Sen. about the catastrophic effects of the summits in all eight #Fight4HER Jeanne Shaheen are expected to reintro- Global Gag Rule in Kenya with our campaign states, engaging a total duce the Global Health, Empowerment, grassroots supporters. of 424 participants — among them and Rights (HER) Act in early February. Reps. Ruben Gallego (AZ-7), Ann 2018 Kirkpatrick (AZ-2), David Price Over the past two years, we’ve made • On the anniversary of Trump (NC-4), and Susan Wild (PA-7). enormous progress, with thousands of imposing his expanded Global Gag In addition, we engaged various people standing up and speaking out for Rule, we staged a visual protest — a state representatives, including the right of every person in the world light projection of snarky mes- New Hampshire State Rep. Latha to have access to comprehensive repro- sages on the Trump International Mangipudi, Arizona State Rep. ductive health care and family planning Hotel in DC — garnering national Athena Salman, Colorado State services. Join us as we continue the battle media attention. We also sent Rep. Leslie Herod, and Ohio State for Health, Empowerment, and Rights. out mobile billboards in Nevada Rep. Kristin Boggs. www.popconnect.org March 2019 — Population Connection 33 On the Road with PopEd Introduction by Lindsey Bailey, Senior Teacher Training Manager d E o p P

all is the busiest time of year for PopEd, and the 2018 season was no exception — over 250 workshops were held from September through December. While we rely heavily on our network of volunteer facilitators to achieve this impressive showing, our staff also travels F throughout North America to fulfill workshop requests and expand our program into new regions. About a quarter of last fall’s workshops were led by PopEd staff. Working face-to-face with educators gives us new perspectives on the benefits of our materials and the impacts of our program. Here’s a sampling of some of the insights gained from our travel last fall.

Kate Anderson Everyone loved learning about Malawi During the professor’s introduction to Education Associate and comparing a typical daily budget for her class of future science educators, she Last September marked my second a family there with that of an average mentioned that she had participated in PopEd visit to Alberta, Canada. I worked family in Canada in our activity, “Global a PopEd workshop as part of her gradu- with future teachers in the Red Deer and Cents.” They were so engaged that they ate program a few years back. She found Edmonton regions, and enjoyed seeing suggested new ways to arrange the paper it so relevant as a student that she has beautiful “Wild Rose Country” in the cup “prey” in our popular carrying capac- included a PopEd workshop in her syl- fall. My favorite campus visit in Alberta ity activity “Panther Hunt.” For example, labus every semester since becoming a was Burman University, Canada’s only knowing that beavers live in small groups, professor. Seventh Day Adventist school. they decided to cluster those cups for an added touch of realism. It was also nice I have heard similar testimonies in I will admit, I was a little nervous when that, unlike their U.S. counterparts, no the past and am struck by how a short my first workshop of the day started with college students here batted an eye about workshop experience can have a last- a reading from a devotional book and a the metric system measurements that we ing effect on participants, even years whole-group prayer. My worry, however, use in our lessons! down the road. I credit this type of sus- proved to be unnecessary. Many of the tained interest in our program to the students enthusiastically shared how Lindsey Bailey quality of our materials and presenta- the PopEd lessons aligned with their Senior Teacher Training Manager tions, and also to our ability to keep religion’s values of environmental stew- We depend on relationships to grow past workshop participants involved ardship and humanitarian work. After the PopEd program, and some of the with continued communication. After our simulation of the “Tragedy of the most important relationships are with attending a workshop, teachers can opt Commons,” students wondered how the the professors who invite us to pres- to receive a bimonthly newsletter to keep sustainable resource distribution game ent in their pre-service classrooms year them up to date with the PopEd pro- would play out in different cultures, after year. On one such trip to New gram and resources; they can also engage especially in more communal-minded Jersey City University last fall, I was through our Facebook and Twitter posts, societies like the indigenous communi- reminded of another important relation- and they can elect to receive targeted ties in their province. ship: the one that we cultivate with the marketing about new products that participants who attend our workshops. they may find useful in their classrooms.

34 Population Connection — March 2019 Nurturing these relationships has clearly if they haven’t started already. Their movement, non-verbal communication, proven effective in the past, and will con- enthusiastic conversations during the and visuals as teaching tools. It was very tinue to be a key part of our work. workshop quickly moved from praise gratifying to hear that our curricula will for the resources to logistical planning be directly applicable to the populations Carol Bliese on gathering props and specific place- these future teachers will serve. Senior Director of Teacher Programs ment in their syllabi. One participant “The activity that stood out to me the isn’t keeping us guessing, noting on her most was the population circle game evaluation form, “Everything was a les- representing how crowded the world son plan and so practical. I thoroughly is and how quickly our population has enjoyed this presentation and will 100 exploded. It gives a tangible, relatable percent use this in the classroom.” sense of our population’s growth.” Isabelle Rios Bringing population growth to life is one Senior Education Associate of our goals in the PopEd program, and Last fall, I had the pleasure of traveling to this quote from a participant’s evalua- Florida to share PopEd resources with stu- tion form indicates that our workshops dents at Florida International University are making that happen. This particular (FIU) and Miami Dade College. Most workshop was for a group of geography of the classes I worked with focused on teachers in Ontario. We covered sev- elementary science education. eral methods for teaching the history of human expansion — the interactive During my workshops I found that stu- simulation mentioned above, our World dents were engaged and energetic, often Population “dot” video, and a graphing scribbling down little notes here and activity comparing population growth there. It wasn’t until we debriefed several curves. activities that I became aware of just how much participants were enjoying the Offering different ways to teach a topic presentation. At FIU, students shared means teachers can select whatever that many of the K-5 students in the area method(s) will fit their students’ vari- are not native English speakers, and they ous learning styles (kinesthetic, spatial, found the hands-on nature of our activi- mathematical, etc.). I’m confident that ties to be an excellent way to break down Top: A student dumps pollutants into a simulated ocean in the activity, “Code Blue” the 24 educators in this workshop will language barriers in their classrooms. Bottom: Students collect “prey” during the be using PopEd lessons down the road, Several of the lessons I presented utilized activity, “Panther Hunt” www.popconnect.org March 2019 — Population Connection 35 Cartoon

36 Population Connection — March 2019 Editorial Excerpts

ccess to birth control is crucial to ensuring women resident Donald Trump is continuing his assault on the can control their lives, plan their families, and, in Affordable Care Act, and women’s health care is the many cases, manage ongoing medical conditions. latest casualty. The Trump administration issued new A Prules last year that are scheduled to take effect this month and Yet by pushing to let more employers deny insurance coverage would allow more employers to deny birth control coverage for contraceptives, the Trump administration is treating birth through their health plans. The rules are billed as “conscience control as some kind of novelty, rather than the medical neces- protections” for employers with religious or moral objections to sity it is for millions of women. contraceptives, but where is the morality in denying millions of women basic health care? Final rules issued by the federal government this month will let many more employers claim religious or moral exemptions The new rules would allow more entities to claim exemptions from providing birth control coverage. And, unlike in many on religious grounds, under the illogical notion that a corpora- cases before, a third party such as an insurance company will no tion can have religious beliefs. They also would let nonprofit longer be required to step in and provide that coverage when organizations and small businesses claim non-religious moral employers refuse to do so. convictions in denying birth control coverage. These rules aren’t upholding the constitutional right to freedom of religion — To preserve women’s access to birth control, the Trump admin- they’re contorting it by making a woman’s access to health istration should retract these rules, which are set to take effect care subject to the religious beliefs of her employer. That also January 14. If the administration fails to reconsider its approach, amounts to blatant sex discrimination. Congress should vote to override the new rules. The administration also has proposed that women whose A separate proposal by the Trump administration would allow employers don’t provide birth control be allowed to obtain it women whose employers claim a religious or moral exemption from federally funded family planning clinics for low-income to access Title X family planning services, which are meant for people. Those clinics already struggle to keep up with demand low-income people. But this plan is woefully insufficient, given and never have enough money. Requiring them to spread their that the federal Title X program is already underfunded and dollars even further to subsidize these new exemptions is an unable to meet current levels of demand. Federal officials didn’t unnecessary drain on scarce public money. And this proposal respond to a question this week about whether the administra- comes with other bitter pills, including new restrictions and tion would also try to increase funding for the Title X program. requirements on clinics that provide abortions.

Rather than continuing what promises to be a prolonged legal By making it easier for employers to deny birth control cov- battle, federal officials should swiftly reverse course. erage, the Trump administration would be making it harder for women to access basic health care and family planning If they do not, members of Congress should not hesitate to pass measures. Religious organizations already enjoyed reasonable legislation protecting women’s contraceptive coverage long into accommodations for opting not to provide contraceptives. The the future. beliefs of CEOs, company presidents, and business owners – November 25, 2018 should be irrelevant beyond their own families. Instead they are being elevated above the health needs of women.

– January 2, 2019 www.popconnect.org March 2019 — Population Connection 37 Population Connection NON PROFIT ORG 2120 L Street NW, Suite 500 US POSTAGE PAID Washington, DC 20037 POPULATION CONNECTION

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