Population, Family Planning, and the Future of Africa
Population, Family Planning, and the Future of Africa
In most African countries, over half the population is under the age of 15. Even if all of those countries were to shift to having just two children, beginning tonight, their total populations would continue to grow for another two decades. Nevertheless, there is hopeful evidence of progress.
Africa's colonial legacy-exploitation, artificial borders, too many small and unviable countries after independence-is the chief source of a catalog of misfortunes that is by now familiar: civil and regional conflict, famine and hunger, land degradation, corruption and ill health. Economically, sub-Saharan Africa lags pitifully behind all other developing regions. Its GDP per-capita growth rate during the 1990s was actually negative. In 2002, the nations of sub-Saharan Africa, with 688 million people, managed a collective gross domestic product of $319 billion-a per-capita average of well under $2 per day. With 11 percent of the world's population, sub-Saharan Africa accounts for only 2 percent of world trade.
Food production has fallen since independence. Although a net food exporter before 1960, Africa has become more dependent on food imports and food aid over the last three decades. From 1974 through 1990, food imports in sub-Saharan Africa rose by 185 percent and food aid by 295 percent. In 1995, food imports accounted for 17 percent of total food needs.
The human condition in Africa remains as daunting as ever. Of the 34 countries on the UN list of Low Human Development indicators, all but four are in Africa. This inevitably means that illiteracy rates are high, infrastructure is inadequate, and health services are rudimentary. The debt burden has certainly been a major constraint: in 2002 Africa's total debt stood at $204 billion, 64 percent of GDP.
Some progress has been made in reducing political instability and civil unrest, but much more needs to be done to sustain economic growth, durable peace, and equitable income distribution. At this writing (July 2004), hostilities between Ethiopia and Eritrea have ended, but the peace is uneasy. Civil wars in Angola and Sierra Leone have also ended. In Sudan a peace agreement is pending, but widespread violence in Darfur continues. The outside armies that were fighting in the Democratic Republic of the Congo have withdrawn, but instability and ethnic conflict persist. Resettlement and reconstruction are still slow in such countries as Burundi, Rwanda, Liberia, and Somalia. The flows of refugees from these conflicts have caused major disruption to neighboring countries.
Two Steps Forward...
These are all difficult problems, but one factor-rapid population growth-has certainly made a lot of them more difficult to solve. It has often been said that the one thing Africa has is plenty of land and that consequently population growth is not a bad thing. It is true that Africa's population density, 249 people per 1,000 hectares, is low compared with the world average of 443. But this simplistic view does not take into account that the natural carrying capacity of much of the land in Africa is low and subject to the vagaries of a capricious climate. It also conveniently ignores the fact that it is the rapidity of population growth which causes so much stress and suffering. Growth rates of over 2.5 percent per year are far higher than those experienced in the past by the now-developed world, and by most other developing regions today. These are occurring largely because death rates have fallen due to immunization and improvements in health care.
But fertility has remained high. In recent decades, urbanization and the breakdown of traditional values have led to more frequent childbearing outside socially accepted norms. African women have suffered most, and the high rate of unsafe abortion-every day, some 10,000 African women resort to this practice-is one evidence of their frustrated desire to control their fertility. Family planning services have been woefully inadequate.
There are encouraging signs that things are beginning to change, but these signs are only sporadic and the tempo is still slow. In recent years, most African governments, nudged by global advocacy efforts and their family planning associations, have come to accept that fewer, better-spaced births lead to healthier children and lower maternal mortality and morbidity. All but a fanatical few have dropped their earlier opposition to family planning as a Western imposition or a neo-colonialist plot to decimate African populations. By the time of the Third African Population Conference, held in Dakar in December 1992 as part of the preparations for the International Conference on Population and Development (ICPD) in Cairo in 1994, delegates were speaking almost unanimously about the importance of family planning, both as a human right and as a development issue.
But there is still a long way to go. In sub-Saharan Africa as a whole, only 17 percent of married women are using contraceptives, as against 50 per cent in North Africa and the Middle East, 39 per cent in South Asia, 76 per cent in East Asia and the Pacific and 68 per cent in Latin America and the Caribbean. Only in a few countries, such as South Africa, Zimbabwe, Botswana, and Kenya, have family planning programs been successful enough to increase contraceptive use to much higher levels.
Kenya provides the most dramatic example. Kenya's fertility fell 22 percent during the 1980s, from 8.3 children per woman in 1978 to 6.5 in 1989. Desired family size fell 35 percent during the same period, from 7.2 to 4.7 children, and contraceptive use rose more than threefold. Although traditional Kenyan values favored large families, they have become less advantageous as rapid population has put pressure on farming land in many areas. Higher female literacy has helped promote new attitudes about family size. Increasingly, parents want to send their children to school, and rising school costs have made it much more expensive to educate large families. By 1998, fertility had fallen further to 4.4 children per woman, and it remained at that level in 2003.
But African governments are now also worrying more specifically about the implications of high population growth rates: in fact, three-quarters of Africans now live in the 24 countries with governments that view their population growth rates as too high. In most African countries, over half the population is under the age of 15, which means there is a vast pent-up demographic momentum throughout the continent. Even if Kenya, for example, were to attain the two-child family overnight, its population would continue to grow for another two generations and would eventually double.
Some reasons for governments' concerns about rapid population growth are social and economic: how will they provide the schools, hospitals, and jobs for the next generation? There is also the question of food supply: in many regions, particularly the Sahel, population growth has exceeded carrying capacity and thus denied the development and security which would encourage a fall in childbearing.
Rapid population growth is also having a serious effect on the natural environment in Africa. Some 500 million hectares of land have been affected by soil degradation during the last half century, including as much as 65 percent of agricultural land. This has been a major factor in constraining food production in Africa to only a 2 percent annual increase, well below the rate of population increase. The number of undernourished people in Africa has more than doubled from 100 million in the late 1960s to roughly 230 million today; perhaps another 150 million are subject to acute food deficits, and possibly as many as 50 million are actually starving. Projections indicate that the region will be able to feed only 40 per cent of its population by 2025.
Although most Africans depend on the land for their livelihood, the land's capacity to produce is ebbing away under the pressure of growing numbers of people who do not have the wherewithal to put back into the land what they are forced to take from it. Trees are being cut down 30 times as fast as they are being replaced, and some 80 million Africans have serious difficulty finding fuelwood. Deforestation and overgrazing leads to declines in soil fertility. In countries like Ethiopia, topsoil losses of as much as 290 tons per hectare have been reported.
As the land's vegetative cover shrinks, its already fragile soils lose the capacity to nourish crops and retain moisture. Agricultural yields fall and the land becomes steadily more vulnerable to variable rainfall, turning dry spells into drought and periods of food shortage into famines. In most parts of Africa you can hear farmers say that it is more difficult to make ends meet, that plots are much smaller and farther away, fallow periods shorter. All these trends impose extra strains on women, who are usually responsible for growing the family vegetables, fetching water, and gathering fuelwood.
Another serious problem is water. About one-third of the world's population already lives in countries with moderate to high water stress, where water consumption is more than 10 per cent of the renewable freshwater supply. Fourteen of these countries are in Africa, and another 11 countries will join them in the next 25 years. Major rivers, like the Limpopo and the Save/Sabi, which flows through Zimbabwe and Mozambique to the Indian Ocean, have dried up and now only flow seasonally. There are signs that flows of other major rivers, including the Chari-Logona, Nile, and Zambezi, are decreasing.
In Africa generally, agriculture supports 66 percent of the population and provides essential exports. Its healthy development is a key to slowing rural-urban migration. But it is totally dependent on a regular supply of fresh water. Water shortages will increasingly become a constraint on economic and social development, especially in countries with limited water supplies, rapid population growth, and/or fast-expanding industry and agriculture.
Maternal Diseases and Deaths
Pregnancy and unsafe abortion are the leading causes of death among women of reproductive age in most African countries. A maternal death may result from direct pregnancy complications, from problems arising at delivery, from abortion or its consequences, from post-delivery complications, or indirectly from pre-existing conditions aggravated by pregnancy.
The maternal mortality rate, which measures the death rate of women due to pregnancy and childbirth, is higher in Africa than on any other continent: 830 deaths per 100,000 live births for the continent as a whole in 2000, and an average of 920 for sub-Saharan Africa. This amounts to almost 700 deaths every day in Sub-Saharan Africa. The high mortality rate masks an even higher morbidity rate: the same afflictions that kill hundreds of thousands of women maim and render sterile many millions more of their sisters. For every woman who dies, 50 to 100 others suffer short-, medium-, or long-term debilities from their pregnancies and deliveries.
At the root of this high maternal mortality and morbidity is a multitude of health and socio-economic problems. Many girls are born prematurely or at low birth weight because their own mothers were malnourished, ill, or overworked. If she survives infancy, an African girl will most likely grow up on a diet that does not meet her minimum nutritional requirements. As a child, she will have a heavy burden of household chores and may receive little or no schooling; almost all African girls receive less education than their brothers, although the literacy gap is beginning to narrow, at least in Botswana, Swaziland, Tanzania, Zambia, and Zimbabwe. She is likely to be married off young, especially if a good bride price is available, and taught that her main role in life is to bear and rear as many children "as God brings." During pregnancy, her needs for adequate rest, good nutrition, and health care are too often ignored.
For these reasons, as well as to reduce the vast number of unsafe abortions, better reproductive health services are badly needed throughout Africa. Such services are also needed to combat sexually transmitted infections (STIs) and HIV. According to the World Health Organization, STIs have become the most common group of notifiable diseases in most countries worldwide, but prevalence rates are particularly high in developing countries. WHO estimates that in 1999 there were 340 million new cases globally in women and men aged 15-49, including 12 million new cases of syphilis, 62 million of gonorrhea, 92 million of chlamydia, and 174 million of trichomoniasis. Among the world's regions, sub-Saharan Africa showed the highest rate of new cases.
In pregnancy and childbirth, these diseases can cause blinding eye infections or pneumonia in babies, chronic abdominal pain, ectopic pregnancies, and infertility. Women are more likely to catch STIs than men. As one medical writer puts it, "Both the transmission and the serious consequences of STIs show a biological sexism. The risk of acquiring gonorrhea from a single coital event in which one partner is infectious is approximately 25 per cent for men and 50 per cent for women.... Moreover, women suffer more serious long-term consequences from all STIs except AIDS, including pelvic inflammatory disease, ectopic pregnancy, chronic pelvic pain, infertility and even cervical cancer." Some STIs, as well as causing pelvic inflammatory disease and infertility-a major tragedy for a young woman in Africa-make more likely transmission of the worst (and incurable) STI, HIV/AIDS.
Here again, Africa is more seriously affected than any other region. Deaths due to HIV/AIDS in Africa will soon surpass the 20 million Europeans killed by the plague epidemic of 1347-1351. Three million people in sub-Saharan Africa were newly infected with the virus in 2003. For the continent as a whole, the prevalence rate has reached 8 percent among adults aged 15-49.
Like other STIs, AIDS affects more women than men; about 13 African women are currently infected for every 10 African men. The incubation period for HIV infection to develop into AIDS, which is up to 10 years in men, is believed to be shorter in women. Factors such as inferior health and social status, polygamy, other STIs, malnutrition, access to care, ear piercing, genital mutilation, and menstruation all lead to easier transmission of HIV. When women are sick with AIDS or die, their children suffer, even if they were not infected themselves at birth.
Although AIDS will have a devastating demographic impact on some African countries, its long-term effect on African population growth will be relatively limited. Even in the 29 most affected African countries, the projected total population of nearly 1.2 billion in 2050 will only be some 10 per cent less than it would have been without AIDS. Other impacts on development are arguably far more important.
The most important factor in containing the spread of HIV is political commitment. Increasingly, African leaders are speaking out loudly, clearly, and repeatedly about AIDS, are seeking to demystify it, and are encouraging discussion about safe sex everywhere from the classroom to the boardroom.
Some Good News
Despite the ongoing conflicts and disheartening statistics on AIDS, the outlook for Africa is improving. In 2001 the members of Africa Unity (AU) met in Abuja, Nigeria, and issued a declaration agreeing to give more emphasis to HIV/AIDS and recommending the allocation of 15 percent of national budgets to health and the integration of HIV programs with programs for sexual and reproductive health. In most African countries, programs are being advocated with greater courage and conviction. NGOs are increasingly accepted as legitimate partners of governments in the field of sexual and reproductive health. The participation of communities is either being actively promoted or tentatively examined. Gender equity and equality are increasingly being promoted; the AU has amended its charter to acknowledge the importance of gender equity. Political commitment, openness, and determination have even proved that AIDS can be reversed.
There might even be said to be a thin silver lining to the HIV epidemic. It has been a much needed wake-up call to many African leaders to address the many problems of the poor, and the result, encouraged as well by pressures from outside, has been more support for poverty alleviation and HIV efforts. And there is a genuine effort to push for more responsive and democratic governance, a truly basic requirement of people-oriented development.
Because family planning and reproductive health programs are so important for both health and demographic reasons, it is essential that more, not fewer, resources be invested in this area. Many programs are new and will need substantial funding as they expand. The numbers of women in the reproductive age groups are increasing, as are the proportions of those women who want to use contraception: today there are nearly 1 billion women of reproductive age in the Third World (projected to rise to over 1.2 billion by 2010). The developing countries generally are meeting or even increasing their budgets for sexual and reproductive health. Unfortunately, with the laudable exception of a few (mainly Scandinavian) countries, most donor contributions have stagnated or even decreased. Surely, Africa's recent successes and new commitments show that it deserves better.
Frederick T. Sai is a physician, long-time public health activist in Africa, and advisor to the president of Ghana on HIV/AIDS. This article is adapted and updated from one that appeared in The Future of Africa: Essays in Honor of David Morse, published in 2003 by the New York Society for International Affairs.
References and readings for each article are available at www.worldwatch.org/pubs/mag/.