In the mid-1980s I had a face-to-face interview with President Hosni Mubarak to discuss family planning. He looked at the population projections I carried and told me he was an Air Force officer and fully understood numbers and graphs. The problem was I could not get him to understand that the way his government was delivering family planning through the health system was insensitive to the needs of poor women. In fact, the health services were so bad that women preferred to deliver a baby at home, and perhaps risk death from postpartum hemorrhage, than go to hospital where they would be treated no better than cattle.
As a physician, I believe women everywhere have a basic human right to family planning information and methods, but Egypt also demonstrates the geopolitical consequences of failure to make family planning easy to obtain.
When I met Mubarak the population of Egypt was 50 million. When I first visited the country over a decade earlier it had been 35 million. One of the people I worked with was a senior Cairo professor of obstetrics. He had to deal with a huge burden of botched abortions and knew perfectly well that Egyptian women wanted fewer children. He knew he had to begin with perceptions instead of an unnecessarily medicalized framework – the road less frequented in family planning.
But how to do you get illiterate peasant women to ask one of the best know doctors in Cairo about something as personal and embarrassing as advice on contraception? My friend’s answer was to pay a peasant woman to sit in his waiting room and gossip to the other patients. She would say, “The professor has a special device from America to stop you getting pregnant, but he only gives it to his private patients.” Many of the women, as they were leaving, screwed up their courage: “Doctor, you have a device to stop me getting pregnant?”
“Who told you that?” he would snap, pretending to be angry. Then he would explain the advantages and disadvantages of intrauterine contraception and offer to insert a device, providing the woman promised not to tell anyone else – which he knew perfectly she would do. It was a grass roots approach to family planning.
In the early 1970s, I had been asked to join a World Bank mission to support the Egyptian government’s family planning program. We visited health centers where sometimes the young doctor, fresh out of medical school, would expect bribes from his patients. One health center was locked and no one could find the key.
I was the only member of the team who had sat in front of women desperate not to be pregnant. Most of the money the Bank was giving was a loan to build health centers. I have nothing against health centers, but it is not the road I would travel to offer family planning in a country like Egypt. I asked why the World Bank was depending in health centers when the need was to take contraceptives to the women’s doorsteps.
No one listened. Nothing changed. The population of Egypt went on growing. Instead of exporting food the country began to import it. The government invested in schools and universities, but it could not create sufficient jobs for the growing number of young men.
Today, with over 80 million people, Egypt imports 60% of its wheat and last year food prices rose by over 50%. Half the population is under age 24 – these are the unemployed, frustrated men who led the demonstrations in El Tahrir Square in central Cairo.
Other countries have gone down the road not taken. In Bangladesh, which is much poorer and less educated then Egypt, tens of millions of women now have just over two children. In the Islamic Republic of Iran, which is much less secular than Egypt, the average Iranian family has two children. When I was last in Teheran I saw the ‘Moral Police’ patrolling a public park waiting to arrest any young couple that might hold hands in public. Yet the government of Iran had the good sense to make a full range of family planning methods widely available in both the cities and villages. The birth rate has plummeted more rapidly than it did in China.
Egyptian women now average three children, which may seem a small increment over two, but demography is an unforgiving task master. By 2050 the population of Egypt will be between 110 to 150 million. Problems with employment, food prices and civil unrest will be even greater than today. I am delighted that people power won out last week, but the future of Egypt is still highly uncertain. As a result of high population growth, even a democratic government will not be able to deliver the jobs and the low-cost food the population expects.
For hundreds of millions of women around the world, access to the information and technologies they need to manage whether and when to have a child is as important a human freedom as a free press, or free elections.
Everyone in the development field, global politics and, yes, presidents of countries – whether dictatorial like deposed Hosni Mubarak in Egypt or corrupt, like Hamid Karzai in Afghanistan – need to understand that when it comes to family planning the key is to listen to what women want, not try to tell them what to do. There is much truth in the last line of Robert Frost’s famous poem, The Road Not Taken, it “has made all the difference.”