Complicated Good News: The Gates Foundation and Contraception

07/11/2012 12:31 PM |

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Yesterday, Melinda Gates announced that her foundation is going to dedicate millions of dollars to improving access to contraception in the developing world. This could potentially save and improve a lot of lives.

According to United Nations figures, about 220 million women in the developing world who do not want to get pregnant, cannot get reliable access to contraception.

This week, the medical journal The Lancet published a series of studies that underpin the campaign.

One said that satisfying the unmet demand for contraception among women who want to limit or space their pregnancies could reduce maternal deaths by 30 percent, saving about 104,000 lives a year caused by complications linked to pregnancy and childbirth.

Better access to contraception would cut unsafe abortions, estimated to account for 13 percent of maternal deaths in the developing world. First pregnancies for very young women and those that are spaced too closely also carry a heightened risk, the study said. [Reuters]

Sounds like a total home run, right? 104,000 lives is a LOT! Make contraception available to women who want to access it, save lives, improve the health of women and children. But it’s a bit more complicated than that. As the Reuters piece points out:

Money is not the only barrier. Controlling population growth has fallen off the development agenda, rendered controversial for decades by coercive programmes like forced sterilisation in India in the 1970s and China’s one-child policy.

Says the Gates Foundation:

It still provokes controversy, not least in the United States where Gates has been criticised by Catholic groups which tend to see contraception and abortion as part of the same issue.

“Its far less controversial than people make it,” says Gates, citing a Gallup poll three months ago in the United |States. “Top of the poll was: 90 percent of Americans think contraceptives are morally acceptable. 82 percent of Catholics think contraceptives are morally acceptable. To me that’s not controversial.

“It’s when you start to broaden the agenda that you find the controversy,” she adds.

Obviously, I think the anti-contraception Catholics can go fuck themselves. It’s not a moral issue in that sense, for me. But it’s the interaction between Gates’s response—that most people have no moral objection to using birth control—and the preceding paragraph. There’s a huge HUGE difference between individual women making individual choices with their bodies and “population control.” And when white, wealthy philanthropists go into “developing” nations, which usually mean nations formerly under the colonial rule of their white, wealthy cohorts, they must be exceedingly careful to understand the difference between those two things.

Perhaps its the language about the greater economic and ecological benefits of limiting African family size. Nobody ever talks about rich people and their family planning decisions in those terms, despite the fact that a kid born to a rich family would almost necessarily have a bigger lifetime carbon footprint than one born to a less-rich family. I understand that large initiatives such as this one have to consider population-wide trends when determining the what would be for the greater good, but it’s imperative that nobody within the initiative lose sight of the fact that no “greater good” trumps a woman’s individual decision about her body, her family, her pregnancies or lack thereof. Ideally, these two ideas—the greater social good and the individual good—are aligned, but there’s a complexity to seeing both goods at the same time when making social policy. It’s not at all clear to me that the Gates Foundation is working with that kind of nuance.

In Maria Bustillos’s excellent piece Our Billionaire Philanthropists, she outlines some of the more troubling aspects of capitalist philanthropy like the Gateses practice. Their campaign to eradicate malaria, for example, is one that the Reuters piece specifically compares this new contraception campaign to, and one that was pretty much a spectacular failure.

The Gates Foundation’s efforts against malaria, for example, may end up doing more harm than good. An apparent rebound of malaria in Senegal last year speaks ominously to former WHO malaria czar Arata Kochi’s warnings against the Gates Foundation’s monopoly on malaria research and policy back in 2008; the Senegal study, published last year in the Lancet, found not only an increase in insecticide-resistant mosquitoes, but also rebound infections in older children and adults. That troubling trend suggests that some Senegalese may have lost their acquired immunity in the years they’d been sleeping under pesticide-treated nets, which the Gates Foundation has been distributing by the millions in Africa. Malaria expert and science writer Sonia Shah laid out the issues for me in an email:

I think the lesson of history is pretty clear that if economic and other conditions remain the same, malaria resurges when control efforts flag or fail. There is certainly growing evidence that this is happening now. [...]

The trouble with malaria is that it fluctuates naturally from year to year and is caused by a multiplicity of factors (climate, geography, housing, people’s immune status, population movements, etc. etc.) that also fluctuate year to year. So to really determine that a decline or resurgence has occurred, you have to measure in decades, not years. Just a few months ago, for instance, the headlines were all about a 40 percent drop in global malaria mortality; today the headlines are all about a huge increase! There’s a lot of hype about malaria, mostly because of the quest for funding, which is a mess right now.

I and others had warned that if the massive scale-up that Gates and Roll Back Malaria were so proud of wasn’t maintained that lives would be lost due to resurgence. Malaria is like a coiled spring; you can depress it by sitting down on it, but as soon as you get up, it jumps back up. [The Awl]

So basically while the Gates Foundation is very good at identifying pressing problems and taking action against them, its track record for actually FIXING complicated issues is not so great. And part of that failure is an unwillingness to listen to experts in the field that have been attempting for years to find solutions, who understand the complicated nuances of the problems. Sometimes a giant sledgehammer of money and an entrepreneurial can-do spirit does, as Ms. Bustillos says, more harm than good.

I sincerely hope that this is not the case with this contraception campaign. I strongly, strongly believe that all people everywhere should have access to all of the safe and affordable contraception that they want. I think everyone should also have access to truthful, unbiased information about safe sex and family planning. On the surface, I am 100% excited about the Gates Foundation’s African contraception initiative. And yet something about it gives me pause. Rich, white Westerners with a history of ignoring cultural nuance coming to tell African women what to do with their bodies…I don’t know. I hope they get this one right.