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Mubarak’s mistake: The road not taken

Malcolm Potts, professor of population and family planning | February 13, 2011

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.” 

Comments to “Mubarak’s mistake: The road not taken

  1. Family planning is a very personal issue for a woman, but a national issue for a country. If we need to match both interests, then the private need like a family planning-method aavilabilty should be made publicly accessible in a way it remains confidential for a woman.

  2. Two things are needed to curb population growth anywhere: accessibility of contraception and the money to buy it. After that, population size is a function of individual and culture values, which is how it should be. Every child should be wanted and welcomed.

    Poor availability of contraception leads to a poorer populace, no matter what their initial wealth. If a woman can afford contraception but she can’t access it (for legal, logistical, or cultural reasons), additional children are practically inevitable. More children means dividing your resources more ways, which significantly decreases the standard of living for all involved.

    Good availability but no money means that poor people get disproportionately poorer as their unplanned family size expands. To decrease the rate of population growth even as the number of people is quickly rising, economics becomes your #1 concern.

    Specifically, you have to find ways to improve the standard of living among the poorest people asap. And a little improvement goes a very long way. Poor women are some of the most astute and self-disciplined financial managers that this world has. And contraception is so cheap, and such a good investment for a woman and her loved ones, that it’s not hard to popularize.

    You know, with the billions or trillions of dollars the US has given Egypt over the last few decades, how much would it cost to provide free contraception to all Egyptian women (who want it) for 10 years? 20 years (1 generation)? Leave the apoplectic imams blustering in their mosques (many of which ban women anyway) and pass out pills at the markets and shoe stores and salons.

    Now that would be efficient Dept. of Defense spending – fewer children, wealthier healthier families, less to stress about, means fewer poor angry young-men-cum-jihadists. Fewer mothers who lose their sons to hate, prison, war, and early deaths.

    Improve national security (for both the US and Egypt) by helping poor women take the actions they already desire.

  3. Unfortunately, policy makers in the United States too need to be re-convinced of the importance of investing in family planning.
    If our Senate chooses to vote to de-fund planned parenthood later this month, the needs of young women and poor women in this country would also be abandoned to the road not taken.

    It would be even more embarrassing for this country to revert to all the problems of unplanned pregnancy after having these services in place.

    Alannah Tomich
    UC Berkeley Undergraduate Public Health

  4. Professor Potts: I was waiting impatiently to see an analysis like yours published in America or in Egypt. To my knowledge, you are the only voice who, since the 25 January revolution in Cairo, pointed out that uncontrolled population growth is an important root cause of the Egyptian dilemma, and that population control is key to any future solution. In certain aspects of public life, Mubarak was flerting with the Islamists and demoting secularists. In the last 30 years, text books and media in Egypt were changed to promote Jihadist concepts such as population growth and hate of non-Muslims and their ideas. For them, population control is a Western conspiracy against Islam. This is explicitly written and can be checked in text books from Kindergarden to high school along with government controlled newspapers. Since it is routine in Egyptian media to blame the West for any local trouble, here is one: Egypt’s population fluctuated around 5 million for thousands of years, until 1900 AD when modern medical inventions and care, introduced by the West, started to reduce infant mortality and increase longevity. I hope the new spirit of the revolution provides genuine progressive leadership in Egypt.

  5. Interesting post, even if you hint too strongly that a lack of family planning is directly associated with recent events in Egypt.

  6. The situation with Iran is not exactly what’s been described here. As far as the government goes, the new policy is to discourage family planning. Two pieces of evidence for this: 1- Very recently the mandatory course titled “Family Planning” has been removed from Iranian universities. 2- There is this new policy of giving a large (comparing to the typical Iranian salaries) sum of money to the parents of every new-born baby.

    There was a period, before the current president Ahmadinejad came to power, when medical professionals were able to convince the Iranian leadership that family planning was the way to go. But it was because at the time, the Iranian leadership was much more susceptible to reason than today. In the view of the current Iranian leadership, family planning is considered something not encouraged, if not discouraged, by Islam. They often quote statements from religious texts that in a nutshell, encourage parents to increase their family size without paying attention to the economic hardship that this may create, because God will provide for them.

  7. I was born in gypt.
    In 1946, Cairo had a population of 2.5 million of which 500 000 were Europeans of all nationalities: French, English, I talian, Greek, armenian, etc. Egypt had a population of 16 million.
    It was a great country to live inexcept that the Moslem Brotherhood was already active and xenophobic.

    Nasser kicked every one out gradually and people knew something had really changed when the greeks, in Egypt since Alexander the Great (wherefore the city of Alexandria, left Egypt.

    Mrs SAdat wrote a book and referring to the population problem asked her husband to do something about it (this was in 1975) and he replied he could do nothing because the Imams refused it absolutely.

    In TV talks around the world you hear people making recommendations on the economies, but rarely if ever, does anyone bring up the population problem especially in the developing world.

    This means inhabitants of these areas can only become poorer in the next few decades and this leaves the door open to extremists because it is easy for them to promise a better life. Masses will believe them until they find out that no real improvement is possible.

  8. I am a professor at the American University in Cairo and when we started Spring semester classes this last week we were encouraged to talk about the revolution and what we all had been experiencing. I told all my classes the big problem they had to solve in our “new Egypt” was over-population. The human burden on resources in Egypt makes real economic,educational, and environmental progress impossible. So,I was delighted to read your “Berkeley Blog” –I am going to post it on my Blackboard websites and distribute it to colleagues. Thank you!

  9. On top of everything else we have to deal with, with this analysis, women will have now to carry on their shoulders the weight of toppling dictators or the prevention of revolutions (depending on one’s point of view). No other culprits found?

  10. When I visited Cairo to attend the UN conference on population and development in 1994 I was astonished to learn Cairo’s population in 1900 had been only 400,000. It must then have been some kind of paradise. Still a maddeningly beautiful and bewitching city, it is just so tragic that it has become also such a hell-hole, so hard due to its large population that it wears people out before their time. Of course slower population growth would not have solved all those problems, but at least it would have made life a bit easier all round and perhaps left space for things to get better. Too late now, in all probability, the numbers are mounting too rapidly. Thank you Malcolm for your insight. If only your words could be imprinted on the minds of those who make the decisions … alas, they all seem preoccupied with other things.

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