The Moment of Lift

by Melinda Gates

  As much as we need women on the ground delivering these services, we also need women in high places with vision and power. One of those women is Dr. Agnes Binagwaho, the former health minister of Rwanda.

  In 2014, Agnes and I coauthored a piece in The Lancet. We called attention to the newborn lives that could be saved if the world could remedy one harsh reality: Most women in low-income countries give birth at home without a skilled attendant.

  Putting a skilled birth attendant at the side of every mother in labor has been one of the great causes of Agnes’s life.

  It’s not a cause anyone would have predicted twenty-five years ago. Agnes was working as a pediatrician in France in 1994 when she began hearing frightening news reports from home. Members of the majority ethnic group, the Hutus, had begun slaughtering minority Tutsis. She followed the horror from afar as almost a million people were murdered in a hundred days. Half of her husband’s family was killed.

  Agnes hadn’t lived in Rwanda since she was 3 years old, when her father moved the family to France so he could go to medical school. But after the genocide, she and her husband decided to return to their country and help rebuild.

  Returning to Rwanda was a shock, especially for a medical doctor who practiced in Europe. Even before the genocide, Rwanda was one of the worst places in the world to give birth, and the conflict made the situation far worse. Almost all the nation’s health workers had either fled or been killed, and wealthy nations weren’t giving health aid. A week after she arrived, Agnes nearly left. But her heart was breaking for those who couldn’t leave—so she stayed, became the longest-serving health minister in her country’s history, and spent the next two decades helping to build a new health system for Rwanda.

  Under Agnes, the health ministry started a program where each Rwandan village (with about 300 to 450 residents) elects three community health workers—one dedicated solely to maternal health.

  These and other changes have been dramatically successful. Since the genocide, Rwanda has made more progress in making birth safer than almost any other nation in the world. Newborn mortality is down by 64 percent. Maternal mortality is down by 77 percent. A generation after Rwanda was considered a lost cause, its health system is studied as a model. Agnes is now working with Dr. Paul Farmer, one of my heroes for bringing healthcare to poor people, first in Haiti and then around the world. Partners in Health, which Paul cofounded, has launched a new health sciences university in Rwanda, the University of Global Health Equity. Agnes is vice-chancellor of the university and is promoting fresh research into what makes delivery work.

  What inspires me most about Agnes’s work in Rwanda, Ati’s work in Indonesia, and Vishwajeet and Aarti’s work in India is that they all show how a passionate emphasis on delivering services can ease the effects of poverty. This underscores the value of Hans Rosling’s stories about extreme poverty: When you begin to understand the daily lives of the poor, it does more than give you the desire to help; it can often show you how.

  When people are not getting healthcare that most others get, the problem is by definition one of delivery. Medicine, services, and skilled assistance are not reaching them. That’s what it means to be poor. They’re on the margins. They’re not getting the benefit of what human beings know how to do for each other. So we have to invent a way of getting it to them. This is what it means to fight the effects of poverty. It’s unglamorous from a technological standpoint, but deeply satisfying from a human viewpoint—innovation driven by the feeling that science should serve everyone. No one should be excluded.

  That is a lesson I have kept close to my heart: Poverty is created by barriers; we have to get around or break down those barriers to deliver solutions. But that’s not all. The more I saw our work in the field, the more I realized that delivery needs to shape strategy. The challenge of delivery reveals the causes of poverty. You learn why people are poor. You don’t have to guess what the barriers are. As soon as you try to deliver help, you run into them.

  When a mother can’t get what she needs to protect her children, it’s not just that she’s poor. It’s something more precise. She doesn’t have access to a skilled birth attendant with the latest knowledge and crucial health tools. Why? There could be many reasons. She doesn’t have information. She doesn’t have money. She lives far from town. Her husband is opposed to it. Her mother-in-law doubts it. She doesn’t think she can ask for it. Her culture frowns on it. When you know why a mother can’t get what she needs, you can figure out what to do.

  If the barrier is distance, money, knowledge, or stigma, we have to offer tools and information that are closer, cheaper, and less tainted by stigma. To fight poverty, we have to see and study the barriers and figure out if they’re cultural, or social, or economic, or geographic, or political, and then go around them or through them so the poor aren’t cut off from benefits others enjoy.

  As soon as we began to spend more time understanding how people live their lives, we saw that so many of the barriers to advancement—and so many of the causes of isolation—can be traced to the limits put on the lives of women.

  In societies of deep poverty, women are pushed to the margins. Women are outsiders. That’s not a coincidence. When any community pushes any group out, especially its women, it’s creating a crisis that can only be reversed by bringing the outsiders back in. This is the core remedy for poverty and almost any social ill—including the excluded, going to the margins of society and bringing everybody back in.

  Back when I was in elementary school, there were two girls who sat at the back of the class, smart girls, but quiet and a little socially awkward. And there were two other girls, socially confident and popular, who sat toward the front of the class. The popular girls in front picked on the quiet girls in the back. I’m not talking about once a week. It was constant.

  They were careful to do it when the teacher couldn’t see or hear—so no one did anything to stop them. And the quiet girls just got quieter. They were afraid to look up and make eye contact because it would bring on more abuse. They suffered terribly, and the pain never went away even after the bullying stopped. Decades later, at a class reunion, one of the popular girls apologized, and one of the girls who was bullied answered, “It’s about time you said something.”

  All of us have seen something like this. And we all had a role in it. Either we were bullies, or we were victims, or we saw bullying and didn’t stop it. I was in that last group. I saw everything I just described. And I didn’t stop it because I was afraid that if I spoke up, the bullies would turn on me too. I wish I had known how to find my voice and help the other girls find theirs.

  As I grew up, I thought abuse like that would happen less and less. But I was wrong. Adults try to create outsiders, too. In fact, we get better at it. And most of us fall into one of the same three groups: the people who try to create outsiders, the people who are made to feel like outsiders, and the people who stand by and don’t stop it.

  Anyone can be made to feel like an outsider. It’s up to the people who have the power to exclude. Often it’s on the basis of race. Depending on a culture’s fears and biases, Jews can be treated as outsiders. Muslims can be treated as outsiders. Christians can be treated as outsiders. The poor are always outsiders. The sick are often outsiders. People with disabilities can be treated as outsiders. Members of the LGBTQ community can be treated as outsiders. Immigrants are almost always outsiders. And in most every society, women can be made to feel like outsiders—even in their own homes.

  Overcoming the need to create outsiders is our greatest challenge as human beings. It is the key to ending deep inequality. We stigmatize and send to the margins people who trigger in us the feelings we want to avoid. This is why there are so many old and weak and sick and poor people on the margins of society. We tend to push out the people who have qualities we’re most afraid we will find in ourselves—and sometimes we falsely ascribe qualities we disown to certain groups, then push those groups out as a way of
denying those traits in ourselves. This is what drives dominant groups to push different racial and religious groups to the margins.

  And we’re often not honest about what’s happening. If we’re on the inside and see someone on the outside, we often say to ourselves, “I’m not in that situation because I’m different.” But that’s just pride talking. We could easily be that person. We have all things inside us. We just don’t like to confess what we have in common with outsiders because it’s too humbling. It suggests that maybe success and failure aren’t entirely fair. And if you know you got the better deal, then you have to be humble, and it hurts to give up your sense of superiority and say, “I’m no better than others.” So instead we invent excuses for our need to exclude. We say it’s about merit or tradition when it’s really just protecting our privilege and our pride.

  In Hans’s story, the mother from the forest lost her life because she was an outsider. She lost her baby because she was an outsider. And her family had a warm memory of the doctor who returned their bodies to the village because they were outsiders. They were not used to being treated with respect. That is why they suffered so much death.

  Saving lives starts with bringing everyone in. Our societies will be healthiest when they have no outsiders. We should strive for that. We have to keep working to reduce poverty and disease. We have to help outsiders resist the power of people who want to keep them out. But we have to do our inner work as well: We have to wake up to the ways we exclude. We have to open our arms and our hearts to the people we’ve pushed to the margins. It’s not enough to help outsiders fight their way in—the real triumph will come when we no longer push anyone out.

  CHAPTER THREE

  Every Good Thing

  Family Planning

  A few days after I visited Vishwajeet and Aarti’s program, which trained community health workers who attended home births, I visited a maternal and newborn health program called Sure Start, which encourages mothers to deliver in clinics with trained birth attendants and medical equipment.

  When I arrived at the project site, I was invited to watch a group of twenty-five pregnant women playing a quiz game on principles of good health, answering questions about early breastfeeding and first-hour newborn care. Then I met with a women’s group centered on pregnant women and their family members, mainly mothers-in-law and sisters-in-law. I asked the pregnant women if they faced any family resistance for participating in the program. Then I asked the mothers-in-law what changes they’d seen since they’d been pregnant with their own children. One older woman told me that she had given birth to eight children at home, but six had died within a week of delivery. Her daughter-in-law was now pregnant for the first time, and the older woman wanted her to receive the best possible care.

  In the afternoon, I was able to visit the home of a mother named Meena who had delivered a baby boy just two weeks before. Meena’s husband worked for daily wages near their home. Their children had all been delivered at home except for the newborn, who was born in a clinic with the support of Sure Start. Meena held her infant in her arms as we talked.

  I asked Meena if the program had helped her, and she gave me an enthusiastic yes. She felt delivering in a clinic was safer for her and the baby, and she had started breastfeeding the same day, which made her feel free to bond with her baby immediately, and she loved that. She was very animated, very positive. She clearly felt good about the program, and therefore so did I.

  Then I asked her, “Do you want to have any more children?”

  She looked as if I’d shouted at her. She cast her eyes down and stayed silent for an awkwardly long time. I was worried that I’d said something rude, or maybe the interpreter had offered a bad translation, because Meena kept staring at the ground. Then she raised her head, looked me in the eyes, and said, “The truth is no, I don’t want to have any more kids. We’re very poor. My husband works hard, but we’re just extremely poor. I don’t know how I’m going to feed this child. I have no hopes for educating him. In fact, I have no hopes for this child’s future at all.”

  I was stunned. People tend to tell me the good news, and I often have to ask probing questions to find out the rest. This woman had the courage to tell me the whole painful truth. I didn’t have to ask. And she wasn’t finished.

  “The only hope I have for this child’s future,” she said, “is if you’ll take him home with you.” Then she put her hand on the head of the 2-year-old boy at her leg and said, “Please take him, too.”

  I was reeling. In a moment, we had gone from a joyous conversation about a healthy birth to a dark confession about a mother’s suffering—suffering so great that the pain of giving her babies away was less than the pain of keeping them.

  When a woman shares her grief with me, I see it as a huge honor. I listen intently, offer sympathy, and then try to point out an upside somewhere. But if I had tried in that moment to say something upbeat to Meena, it would have been false and offensive. I asked her a question and she told me the truth; it would have denied her pain to pretend to be positive. And the pain she described was beyond anything I could imagine—she felt the only way to help her children live a good life was to find them another mother.

  I told her as gently as I could that I had three children of my own, and that her children loved her and needed her. Then I asked, “Do you know about family planning?” She said, “I do now, but you people didn’t tell me before, and now it’s too late for me.”

  This young mother felt like a complete failure, and so did I. We had totally let her down. I was so overwhelmed with emotion, I don’t even recall how we parted or how I said good-bye.

  Meena dominated my mind for the rest of the trip. It took me a long time before I could take it all in. Clearly, it was good to help her deliver in a facility, but it wasn’t good enough. We weren’t seeing the whole picture. We had a maternal and newborn health program, and we talked to expecting mothers about their needs in maternal and newborn health. That was the lens we looked through to see the work, but the lenses we should have been looking through were the eyes of Meena.

  When I talk to women in low-income countries, I see very little difference in what we women all want for ourselves and our children. We want our kids to be safe, to be healthy, to be happy, to do well in school, to fulfill their potential, to grow up and have families and livelihoods of their own—to love and be loved. And we want to be healthy ourselves and develop our own gifts and share them with the community.

  Family planning is important in meeting every one of those needs, no matter where a woman lives. It took a woman with courage to burn this message into me, and her pain became a turning point in my work. When one person tells me a harsh truth, I can be sure that she’s speaking for others who aren’t as bold. It makes me pay better attention, and then I realize that others have been saying the same thing all along, just more softly. I haven’t heard it because I haven’t really been listening.

  Shortly after I spoke to Meena, I traveled to Malawi and paid a visit to a health center. The center had a room for vaccinations, a room for sick kids, a room for HIV patients, and a room for family planning. There was a long line of women waiting to visit the family planning room, and I talked to a few of them—asking where they had come from, how many children they had, when they started using contraceptives, what kind of contraceptives they used. My nosiness was matched by the women’s eagerness to talk about their lives. One woman told me that she had come to get her injection but didn’t know if it would be available, and all the other women nodded. They said they would walk ten miles to the health clinic not knowing if the shot would be in stock when they got there, and many times it wasn’t. So they’d be offered some other kind of contraceptive. They might be offered condoms, for example, which clinics tended to have in good supply because of the AIDS epidemic. But condoms are often unhelpful for women trying to avoid pregnancy. Women have told me over and over again, “If I ask my husband to wear a condom, he will beat me up. It’
s like I’m accusing him of being unfaithful and getting HIV, or I’m saying that I was unfaithful and got HIV.” So condoms were useless for many women, and yet health clinics would claim they were stocked up on contraceptives when all they had was condoms.

  After I heard most of the women tell the same story about walking a long way and not getting the shot, I stepped inside the room and found that, in fact, the clinic did not have the shot everyone had come for. That wasn’t a minor inconvenience for these women. It wasn’t just a matter of driving to the next pharmacy. There was no pharmacy. And they had come miles on foot. And there were no other contraceptives these women could use. I have no idea how many of the women I met that day became pregnant because the health center was out of stock.

  An unplanned pregnancy can be devastating for women who can’t afford to feed the children they already have, or who are too old, too young, or too ill to bear children. My visit with Meena opened my eyes to women who didn’t know about contraceptives. My visit to Malawi opened my eyes to women who knew about contraceptives and wanted contraceptives but couldn’t get them.

  It hadn’t come as a revelation to me that women want contraceptives. I knew it from my own life, and it was one of the things we supported at the foundation. But after these trips, I began to see it as central, as the first priority for women.

  When women can time and space their births, maternal mortality drops, newborn and child mortality drops, the mother and baby are healthier, the parents have more time and energy to care for each child, and families can put more resources toward the nutrition and education of each one. There was no intervention more powerful—and no intervention that had become more neglected.

  In 1994, the International Conference on Population and Development in Cairo drew more than 10,000 participants from around the world. It was the largest conference of its kind ever held and a historic early statement on the rights of women and girls. It urged the empowerment of women, set goals for women’s health and education, and declared that access to reproductive health services, including family planning, is a basic human right. But funding for family planning had dropped significantly since Cairo.