1. Family Planning: Progress, Lessons Learned, & the Unfinished Agenda Presentation to the Allan Rosenfield Award Ceremony Association of Reproductive Health Professionals, Planned Parenthood Federation of America National Medical Committee, Society of Family Planning Annual Meeting: Reproductive Health 2009 J. Joseph Speidel, MD, MPH UCSF Bixby Center for Global Reproductive Health 1 October 2009, Los Angeles, CA

2. Faculty Disclosure J. Joseph Speidel has no financial interests or affiliations to disclose. Note: Additional faculty, staff, and committee disclosures printed in final program.

3. Learning Objectives At the conclusion of this session, participants should be able to: – Understand political & policy environment during early years of foreign aid for population & family planning programs. – Describe the strategic planning processes for funding in two major programs: USAID & the Hewlett Foundation.

4. Learning Objectives (continued) – Describe background & history of family planning and reproductive health programs and institutions. – Describe the results of USAID-supported research on new fertility regulation methods. – Understand the lessons learned over 40 years of population policy research and programs. – Identify unfinished agenda for population, family planning, abortion & reproductive health.

5. Messages of This Presentation Career Highlights Family Planning and Population Progress The Unfinished Agenda

6. U.S. Agency for International Development, 1969-1983 Director, Research Division Director, Office of Population Key Colleagues: Rei Ravenholt, Duff Gillespie, Tom Merrick, Steve Sinding, Sarah Clark, Sara Seims, Elizabeth Maguire, Jarrett Clinton, Tim Sprehe, Randy Backlund

7. Six USAID Program Goals 1) Demographic & Social Data Demographic and Health Surveys 2) Population Policies Social Science Research 3) Means of Fertility Control Sterilization, IUDs, condoms and microbicides $6 million to improve abortion – prostaglandins, antiprogestins and manual uterine aspiration (MUA) Family Health International for clinical trials

8. USAID Program Goals (contd) 4) Delivery of Family Planning Services Operations research Service delivery through developing country governments, UNFPA & NGOs (e.g. IPPF, Pathfinder, Engender Health) 5) Information & Knowledge Population Communication Services and Population Information Program 6) Human & Institutional Capacity Training through multiple institutions

9. USAID Funds 1969, first year at AID: annual budget = $50 million 1983, final year at AID: annual budget = $250 million

10. Population Action International (PAI), 1983-1995 Vice President President Key Colleagues: Sharon Camp, Craig Lasher, Catherine Cameron, Patty McGrath, Bob Engleman, Susan Rich, Bob Wallace, Shanti Conley

11. PAI Strategies Focus on policy… both for damage control & advocacy – 150 studies, wall charts, & fact sheets – 750 interviews for print media – 250 radio, TV, & personal appearances

12. PAI Studies Major countries (e.g. China, India) Major institutions (e.g. USAID, World Bank) Studies of funding needs for ICPD – first UN Conference to identify funding targets

13. The William & Flora Hewlett Foundation, 1995-2003 Directed population program Triple A Strategy: Advocacy Adolescents Abortion Key colleagues: Wendy Sheldon, Tamara Fox, Nicole Gray

14. Hewlett Foundation Programs Grew from 90 projects with $20 million to 200 projects with $100 million Population advocacy programs in all major foreign aid donor countries Increase of $200 million in annual funding for population assistance from non-U.S. donor governments

15. Hewlett Foundation Programs Advanced degree programs Funders Network on Population, Reproductive Health and Rights Foundations support for population work increased: 1995 = $100 million annually since 1999 = $300-500 million annually

16. Hewlett Foundation Programs Contraceptive development research Environmental organizations to explore population & environment links Advocacy for education in developing countries – USAID education budget increased from $100 to $200 million

17. UCSF Bixby Center for Global Reproductive Health, 2003-present Director for Communication, Development & External Relations 200 faculty and staff $45 million budget Working on: Family PACT program, emergency contraceptive information, population & environment links, funding needs, advocacy for USAID, and LARC with Cynthia Harper & Kirsten Thompson

18. Family Planning: A 40 Year Report Card In our field there is always good news and bad news… – Sharon Camp

19. Policy & Programs 1969*2009 USAID budget$50 million$545 million UNFPA budget$5 million$700 million Governments in support of family planning About 50About 185 * The USAID Office of Population and UNFPA were established in 1969.

20. Family Planning Delivery Systems 19692009 Small scale government & NGO programs Private health care providers Large scale government & NGO programs Private health care providers Social marketing Household & community distribution Use of field workers

21. Changes in Family Planning in Developing Countries 19692009 Proportion of couples using family planning 35%61% Number of couples75 million630 million Annual expenditures on family planning programs $1-2 billion$8 billion Number of couples in need of family planning 200 million Needed funding increase$4 billion

22. Changes in Total Fertility Rates 195019692009 Children per woman, developed countries 2.82.21.7 Children per woman, developing countries 6.25.22.7 Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. 2009. World Population Prospects: The 2008 Revision

23. Population Size & Growth by Year 1900195019692009 Developed countries 0.5 billion0.8 billion1.0 billion1.2 billion Developing countries 1.1 billion1.7 billion2.6 billion5.6 billion Annual growth 15 million48 million75 million83 million

24. Why Does This Unfinished Agenda Matter? Human rights – Womens status, health, & welfare Health – Poor reproductive health is a leading cause of illness & death Socioeconomic development – Rapid population growth hampers economic growth, perpetuating poverty Environment – Growth of human numbers & consumption

25. The Most Critical Problems Environmental sustainability requires stabilized population Many of the poorest countries, mainly in sub-Saharan Africa, still have high fertility Family planning now a lower priority for international development organizations Most governments in poor countries have appropriate family planning policies, but insufficient funds Adapted from: Cleland J, et al. Family planning: the unfinished agenda. The Lancet 2006; 368: 1810-27.

26. Unintended Pregnancies Contribute to Population Growth Millions each yearWorldU.S. Pregnancies2106.4 Unintended pregnancies803.1 Abortions421.3 Unplanned births341.4 Total population growth832.7

27. Unmet Need for Abortion Care Deaths among women subsequent to unintended pregnancy, 1995-2000 Due to unsafe abortion400,000 Due to pregnancy, labor, delivery or other causes 300,000 Source: Daulaire N, Leidl P, Mackin L, Murphy C, Stark L. Promises to keep: the toll of unintended pregnancies on womens lives in the developing world. Washington D.C.: Global Health Council; 2002.

28. What We Need to Do The keys to effective family planning programs: – High-level political commitment – Broad support from leadership groups – Adequate funding – Smaller families & modern contraception legitimized through mass media, etc. – Availability of a variety of methods through medical facilities, social marketing, & outreach services – Abortion care Adapted from: Cleland J, et al. Family planning: the unfinished agenda. The Lancet 2006; 368: 1810-27.

29. Family Planning Services Funding Lower Now than in 1995 Source: UNFPA & NIDI Resource Flows for Population Activities.

30. Warnings About Population & Environment from Scientists Earth is finite… Its ability to provide for growing numbers of people is finite. And we are fast approaching many of the earths limits… We must stabilize world population. – World Scientists Warning to Humanity, 1992 Signed by 1700 scientists, including 104 Nobel Prize winners If we do not stabilize population in voluntary, humane ways, it will be done for us by Nature; it will be done brutally, relentlessly and whether we wish it or not. – Henry W. Kendall, 1992 Nobel Laureate & Chairman of the Union of Concerned Scientists

31. Recent Headlines Starvation ravages East Africa – TheStar.com 8/26/09 Asia facing unprecedented food shortages, UN report says…population expected to grow by 1.5 billion over next 40 years – The Guardian 8/27/09 Amazon destruction accelerating – BBC News 5/19/05 Climate Change Study: Poor Nations Need $500 Billion – SF Chronicle 9/2/09

32. Millennium Ecosystem Assessment Humans have changed ecosystems rapidly and extensively over the past 50 years Increasing demands for: – Food – Fresh water – Timber – Fiber – Fuel

33. Forests Are Dwindling Global forest cover has declined by 50% since pre-agricultural times

34. Food Security Deteriorating The FAO estimates there are 900 million chronically hungry people In 15 African countries, 35% are hungry In developing countries, 1 in 3 children under 5 years old suffer stunting

35. Fisheries Are Collapsing 75% of global fisheries have been over-fished or fished to their biological limit

36. Cropland Shrinking Due to Soil Erosion & Desertification The productive capacity of 25% of all agricultural landsan area equal to the size of India and China combinedhas already been degraded

37. By 2025, 3/4 of people will face some degree of water scarcity Overuse depleting aquifers in China, India, and the U.S.countries with half the worlds people and the largest grain producers Melting glaciers and decreased snow melt threaten irrigation Water Shortage a Growing Problem

38. Water Scarcity Increases with Population & Climate Change Climate change alone will increase water scarcity Climate change plus population growth will cause further scarcity Source: Rogers P. Facing the Freshwater Crisis. Scientific American August 2008: 46-53.

39. Crop and Range Lands Already Less Productive Grain production peaked in 1984 at 342 kg/person In 2006, it was 302 kg/person 195020082050 Population (billions)2.66.79.2 Hectares/person0.230.100.073

40. Climate Change Will Cause Further Food Security Deterioration Historical record high temperatures may become the norm by 2100 1˚ Celsius increase in norms will likely cause a 2.5-16% decrease in crop yield More destructive storms will damage crops, destroy topsoil 10 meter sea level rise could: – displace 600+ million people – flood large areas of cropland & rice-farming floodplains

41. Climate Stabilization Is Essential We have much of the needed technology Move to electric economy powered by: Wind Photovoltaic Other renewables (hydro, geothermal, biomass) Improve transportation by investing in: High speed electric trains Bicycle and pedestrian friendly streets Plug-in hybrid cars Raise energy efficiency of appliances, lighting, heating of homes and buildings Reuse and recycle materials Minimize consumption of meat

42. New Economies Can Restore Natural Systems Sequester carbon by replanting forests Rebuild soil through plantings & improved farming practices Restore fisheries with marine reserves & protected coral reefs & wetlands Preserve fresh water resources by improving irrigation practices & developing sanitary composting toilets (2.6 billion people now lack sanitation facilities)

43. Cost of Inaction Will Be High Every year: – Half a million women die, 5 million suffer serious illness from complications of unsafe childbirth & abortion – 80 million women experience unintended pregnancy Population growth will threaten: – Social & economic progress – Preservation of the environment – Efforts to improve womens health & welfare A world with 11 billion people in 2050

44. A Strategy for Family Planning: The Three Ps P erfect – through research P romote – through advocacy P rovide – through universal availability

45. To save ourselves we dont need new technology: we just need the political will to face up to our problems of population and the environment. – Jared Diamond, 1/1/2005 The Ends of the World as we Know Them The New York Times Yes We Can

46. Thank you!