Categories
Contraception Hope Public Health

Discover a Success Story in Africa

Smoking hut in northern Ghana

            Last month I wrote about the 5 countries I have enjoyed visiting in Africa, including citing their amazingly low per capita GDP. Although most of the population growth over the next decades is predicted to occur on that continent, I see some rays of hope.

            There are two places in the world where studies have been done on ways to increase voluntary family planning, along with other important medical research. One is Matlab, Bangladesh and the other is Navrongo, northern Ghana. I had never heard of the Navrongo studies until shortly before visiting there! 

            Both Matlab and Navrongo have shown that community health workers can improve health significantly. In addition to family planning, the Ghanaian studies studied several successful interventions, including vitamin supplementation and mosquito nets treated with an insect repellant. Their family planning research showed that it is possible to increase contraceptive use and slow population growth even in an impoverished, poorly educated population. This is especially important research since Navrongo is close to the Sahel, and the people there are similar to Sahelians in their preference for large families.

            In 1995, the beginning of the Navrongo studies, the average woman had about 5 children. Fifteen years later, in 2010, that number had dropped to a bit over 4, both in the Navrongo control group and in the country as a whole. One of the interventions decreased the fertility further, to 3.7; a significant reduction.  Now, a decade later, the fertility rate for the whole country is 3.7 children per woman. That group was ten years ahead of the rest of the country! This group combined specially trained community health nurses (as opposed to stationing them at a clinic or hospital) and “zurugelu”.

            “Zurugelu” means “togetherness for the common good”, and was male-centered in the past. For a better explanation, I asked one of the investigators who had worked in Navrongo what “zurugelu” meant. Here is Dr. James Phillips’ reply:

“The zurugelu approach is a social engagement strategy that involves merging the organizational system of primary health care provision with the traditional system of social organization and governance.  When gender problems were evident, we attempted to turn patriarchy on end by working with women’s social groups in ways that were traditionally dominated by men.  Social events, termed “durbars”, were traditionally male events that were led by traditional male social leaders.   To build women’s autonomy and roles, we worked with leaders to eventually have women’s convened and women’s led durbars.  We also had gender outreach activities for responding to the needs of women.   As such, the “zurugelu” approach was a gender development strategy.”

(A “durbar” is a meeting of men with their chiefs.)

            It is interesting that neither community health nurses nor zurugelu alone had much effect on fertility. Even though the nurses educated women about family planning and supplied the necessary materials, fertility did not decrease significantly in the regions where they were introduced but didn’t have zurugelu. Nor did zurugelu alone have much effect by itself. It took both working together for the fertility to come down.

            The need for both nurses and zurugelu is a very important observation. The statement has been made frequently that worldwide over 200 million women want to limit their fertility but don’t have access to modern contraception. Since the nurses provided that access, we know that access alone isn’t enough—at least in this group of people. Apparently tradition and paternalism were significant barriers to using contraception. It took zurugelu to change attitudes before people made the most of what family planning was available.

            What difference did zurugelu make? This traditionally male function opened the eyes of men to the needs of women. Furthermore, the Navrongo programs strengthen the roles of women. 

            Now, back to my visit in Ghana. It was dusk as we were driving from Navrongo back to Nalerigu. We passed a straw hut with smoke emerging from its roof.

            “Is it on fire?” I asked.

            “No”, my host replied. “She’s just cooking the evening meal.”

            Although there is much beauty in northern Ghana, and everyone I met was friendly and warm, my impression is that life is difficult. Now that child mortality is a fourth of what it was 50 years ago, people will benefit from smaller families as well as more education.

© Richard Grossman MD, 2022

Categories
Population

Pay attention to Population Issues

A friend recently asked why people don’t pay more attention to population issues. Between us we came up with several explanations.
Here is the combined list that we put together, with my comments. Do you know other reasons? Email me if you do!

1. The increase in population is so slow that it is difficult to notice. True! But that is why we have census figures, which show that our population is rising geometrically (like compound interest). Other figures show that we are using resources that should belong to our progeny.
2. We are accustomed to looking at near causes, not ultimate causes. It is easy to see that there are more extremes of weather, and to read about climate change, but how many people actually connect those facts with the underlying cause—more people emitting greenhouse gases?
3. Population issues have to do with family size selection, and that is ultimately a personal decision. True again! Fortunately, people are choosing to have smaller families. Unfortunately, there are many barriers in their way. We need more research on safe and effective contraception, and we need to make all methods available to all people with little or no expense.
(An aside. Some people accuse me of advocating “population control”. Other than using the term “birth control”, I have assiduously avoided the word “control”. Indeed, I believe that people should have as many children as they want—including none. My role is to help people achieve their family size goals.)
4. Religions tend to either promote large families or prohibit contraception—or both. Although I believe in freedom of religion (as does the Constitution of the United States), I also believe in the ability of people to use their God-given brains. Most religious prohibitions date back to the era when “…Be fruitful, and multiply” was more relevant.
5. Large size, whether it be vehicle or family size, is an important attribute. This seems to be a male thing. Get over it, guys!
6. Many otherwise reasonable people don’t realize that there are limits to growth. Or, perhaps, they just never thought about the possibility of limits. Our European forefathers came to a sparsely populated continent and enjoyed its bounty. Regrettably, the level of resource usage that we have enjoyed cannot go on forever.
7. The International Conference on Population and Development turned away from population and toward reproductive health (RH). The reasons were good. Concentrating on population, in India for example, had led to coercing people to be sterilized. RH would include family planning, but RH includes other important services such as prevention and treatment of sexually transmitted diseases.
8. The influence of vocal anti-abortion activists. Many people who are against abortion associate population issues with abortion. Remember that the best way to slow population growth—and to prevent abortions—is with good access to modern contraception
9. The success of family planning and attention to declining birth rates. Indeed, most rich countries (and many poorer ones) have fertility rates that will eventually lead to stable population sizes—but there are still many other countries that have high growth rates.
10. Many people confuse the decreasing rate of growth with population shrinkage. Wrong! The world’s population is still growing by 80 million people a year, and the overshoot of our global Ecologic Footprint is 50%. That means that we are far from being sustainable.
11. The media don’t pay much attention to population issues. This is the reason for this column! For more than fifteen years the Herald has been the only newspaper in the country—perhaps in the world—to carry a regular column treating population issues.
12. People deny that the world will be very different in the future than what we have known. It is easy to just assume that the world will continue with the status quo, but oh, so wrong!

I have left a couple of reasons out of this article. Some people believe we need growth for our economy to thrive; last month’s article dealt with growth. More troublesome is how we can support the increasing numbers of old people with fewer young people coming along.
Happily, National Geographic has ignored the taboo against population. This prestigious magazine is running a series of articles in 2011. January’s cover reads: “Population 7 billion: How your world will change”.
Many of us will not be around long enough to see our world deteriorate much more. It is our kids and grandkids who will feel the effects the most.