Melinda Gates: Let's put birth control back on the agenda (1)

Today, I’d like to talk with you about something that should be a totally uncontroversial topic.

But, unfortunately, it’s become incredibly controversial. This year, if you think about it, over a billion couples will have sex with one another.

Couples like this one, and this one, and this one, and, yes, even this one. (Laughter)

And my idea is this -- all these men and women should be free to decide whether they do or do not want to conceive a child.

And they should be able to use one of these birth control methods to act on their decision. Now, I think you’d have a hard time finding many people who disagree with this idea. Over one billion people use birth control without any hesitation at all. They want the power to plan their own lives and to raise healthier, better educated and more prosperous families. But, for an idea that is so broadly accepted in private, birth control certainly generates a lot of opposition in public.

Some people think when we talk about contraception that it’s code for abortion, which it’s not. Some people -- let’s be honest -- they’re uncomfortable with the topic because it’s about sex. Some people worry that the real goal of family planning is to control populations. These are all side issues that have attached themselves to this core idea that men and women should be able to decide when they want to have a child. And as a result, birth control has almost completely and totally disappeared from the global health agenda. The victims of this paralysis are the people of sub-Saharan Africa and South Asia.

Here in Germany, the proportion of people that use contraception is about 66 percent. That’s about what you’d expect. In El Salvador, very similar, 66 percent. Thailand, 64 percent. But let’s compare that to other places, like Uttar Pradesh, one of the largest states in India. In fact, if Uttar Pradesh was its own country, it would be the fifth largest country in the world. Their contraception rate -- 29 percent. Nigeria, the most populous country in Africa, 10 percent. Chad, 2 percent. Let’s just take one country in Africa, Senegal. Their rate is about 12 percent. But why is it so low?

One reason is that the most popular contraceptives are rarely available. Women in Africa will tell you over and over again that what they prefer today is an injectable. They get it in their arm -- and they go about four times a year, they have to get it every three months -- to get their injection. The reason women like it so much in Africa is they can hide it from their husbands, who sometimes want a lot of children. The problem is every other time a woman goes into a clinic in Senegal, that injection is stocked out. It’s stocked out 150 days out of the year. So can you imagine the situation -- she walks all this way to go get her injection. She leaves her field, sometimes leaves her children, and it’s not there. And she doesn’t know when it’s going to be available again. This is the same story across the continent of Africa today. And so what we’ve created as a world has become a life-and-death crisis.

There are 100,000 women [per year] who say they don’t want to be pregnant and they die in childbirth -- 100,000 women a year. There are another 600,000 women [per year] who say they didn’t want to be pregnant in the first place, and they give birth to a baby and her baby dies in that first month of life. I know everyone wants to save these mothers and these children. But somewhere along the way, we got confused by our own conversation. And we stopped trying to save these lives. So if we’re going to make progress on this issue, we have to be really clear about what our agenda is.

We’re not talking about abortion. We’re not talking about population control. What I’m talking about is giving women the power to save their lives, to save their children’s lives and to give their families the best possible future. Now, as a world, there are lots of things we have to do in the global health community if we want to make the world better in the future -- things like fight diseases.

So many children today die of diarrhea, as you heard earlier, and pneumonia. They kill literally millions of children a year. We also need to help small farmers -- farmers who plow small plots of land in Africa -- so that they can grow enough food to feed their children. And we have to make sure that children are educated around the world. But one of the simplest and most transformative things we can do is to give everybody access to birth control methods that almost all Germans have access to and all Americans, at some point, they use these tools during their life. And I think as long as we’re really clear about what our agenda is, there’s a global movement waiting to happen and ready to get behind this totally uncontroversial idea. When I grew up, I grew up in a Catholic home.

I still consider myself a practicing Catholic. My mom’s great-uncle was a Jesuit priest. My great-aunt was a Dominican nun. She was a schoolteacher and a principal her entire life. In fact, she’s the one who taught me as a young girl how to read. I was very close to her. And I went to Catholic schools for my entire childhood until I left home to go to university. In my high school, Ursuline Academy, the nuns made service and social justice a high priority in the school. Today, in the [Gates] Foundation’s work, I believe I’m applying the lessons that I learned in high school. So, in the tradition of Catholic scholars, the nuns also taught us to question received teachings.

And one of the teachings that we girls and my peers questioned was is birth control really a sin? Because I think one of the reasons we have this huge discomfort talking about contraception is this lingering concern that if we separate sex from reproduction, we’re going to promote promiscuity. And I think that’s a reasonable question to be asked about contraception -- what is its impact on sexual morality? But, like most women, my decision about birth control had nothing to do with promiscuity.

I had a plan for my future. I wanted to go to college. I studied really hard in college, and I was proud to be one of the very few female computer science graduates at my university. I wanted to have a career, so I went on to business school and I became one of the youngest female executives at Microsoft. I still remember, though, when I left my parents' home to move across the country to start this new job at Microsoft.

They had sacrificed a lot to give me five years of higher education. But they said, as I left home -- and I literally went down the front steps, down the porch at home -- and they said, "Even though you’ve had this great education, if you decide to get married and have kids right away, that’s OK by us, too." They wanted me to do the thing that would make me the very happiest. I was free to decide what that would be. It was an amazing feeling. In fact, I did want to have kids -- but I wanted to have them when I was ready.

And so now, Bill and I have three. And when our eldest daughter was born, we weren’t, I would say, exactly sure how to be great parents. Maybe some of you know that feeling. And so we waited a little while before we had our second child. And it’s no accident that we have three children that are spaced three years apart. Now, as a mother, what do I want the very most for my children? I want them to feel the way I did -- like they can do anything they want to do in life. And so, what has struck me as I’ve travelled the last decade for the foundation around the world is that all women want that same thing. Last year, I was in Nairobi, in the slums, in one called Korogocho -- which literally means when translated, "standing shoulder to shoulder.

And I spoke with this women’s group that’s pictured here. And the women talked very openly about their family life in the slums, what it was like. And they talked quite intimately about what they did for birth control. Marianne, in the center of the screen in the red sweater, she summed up that entire two-hour conversation in a phrase that I will never forget. She said, "I want to bring every good thing to this child before I have another." And I thought -- that’s it. That’s universal. We all want to bring every good thing to our children. But what’s not universal is our ability to provide every good thing.

So many women suffer from domestic violence. And they can’t even broach the subject of contraception, even inside their own marriage. There are many women who lack basic education. Even many of the women who do have knowledge and do have power don’t have access to contraceptives. For 250 years, parents around the world have been deciding to have smaller families.

This trend has been steady for a quarter of a millennium, across cultures and across geographies, with the glaring exception of sub-Saharan Africa and South Asia. The French started bringing down their family size in the mid-1700s. And over the next 150 years, this trend spread all across Europe. The surprising thing to me, as I learned this history, was that it spread not along socioeconomic lines but around cultural lines. People who spoke the same language made that change as a group. They made the same choice for their family, whether they were rich or whether they were poor. The reason that trend toward smaller families spread was that this whole way was driven by an idea -- the idea that couples can exercise conscious control over how many children they have. This is a very powerful idea. It means that parents have the ability to affect the future, not just accept it as it is.