The Moment of Lift

by Melinda Gates

  The speaker was Jane Otai, who had served as my translator when I spoke to Marianne. After growing up in Korogocho in a family of seven children, Jane had left to earn a university degree, and then returned to help girls who faced the same challenges she had.

  Jane talked to the conference about growing up poor and said, “My mother told me, ‘You can become what you want to become. All you have to do is study very hard—and wait. Don’t have children as early as I did.’” Jane closed by saying, “Because someone told me about family planning very early, I was able to space my children and delay my first pregnancy. That is why I am here. If not for family planning, I would be like any other child in Korogocho.”

  After the Summit—a Bit of the Old Conversation

  The summit was hailed as a success, with unprecedented pledges of financial support and partnership from organizations and governments around the globe, but I learned pretty quickly that changing the conversation would still be difficult.

  Immediately after the summit, I was singled out for criticism in a front-page story in L’Osservatore Romano, the official Vatican newspaper. I had “gone astray,” it said, and was “confused by misinformation.” It went on to say that every foundation is free to donate to whatever cause it wants, but not “to persist in disinformation and present things in a false way.” The article charged that I was dismissing or distorting the value of natural family planning, and suggested that I was being manipulated by corporations who stood to gain from selling contraceptives. The movement we had launched at the summit to expand access to contraceptives was based on “an unfounded and second-rate understanding,” it said. I did notice that the article focused on me, and corporations, and Church teaching, but not the needs of women.

  Forbes later said the story showed that I “could take a punch.” I expected the punch—I also expected the online comments that referred to me as “former Catholic Melinda Gates” or “so-called Catholic Melinda Gates”—but it stung anyway. My first reaction was “I can’t believe they would say that!” (That’s probably a typical response for a beginner in public life!) After a couple of days, though, I had calmed down, and I got why the Church said what it said. I didn’t agree, but I understood.

  I have met with high-ranking officials of the Church since the conference, but our meetings didn’t focus on doctrine or differences. We talked about what we could do together for the poor. They know that I understand the basis of the Church’s opposition to contraceptives, even though I don’t agree. They also know we share some similar concerns. We are both opposed to any effort to coerce women to limit the size of their families, and we are both opposed to wealthy countries imposing their cultural preference for small families on traditional societies. If a woman does not want to use contraceptives because of her faith or values, I respect that. I have no interest in telling women what size families to have, and no desire to stigmatize large families. Our work in family planning leaves the initiative to the women we serve. That’s why I believe in voluntary family planning and support a wide range of methods, including natural fertility awareness methods for any woman who prefers them.

  Obviously, though, I’ve felt the need to express my differences with the Church. Contraceptives save the lives of millions of women and children. That’s a medical fact. And that’s why I believe all women everywhere, and of any faith, should have information on the healthy timing and spacing of pregnancies, and access to contraceptives if they want them.

  But there is a big difference between believing in family planning and taking a lead advocacy role for a cause that goes against a teaching of my church. That is not something I was eager to do. When I was trying to decide if I should go ahead, I talked it over with my parents, with priests and nuns I’ve known since childhood, with some Catholic scholars, and with Bill and the kids. One of my questions was “Can you take actions in conflict with a teaching of the Church and still be part of the Church?” That depends, I was told, on whether you are true to your conscience, and whether your conscience is informed by the Church.

  In my case, the teachings of the Catholic Church helped form my conscience and led me into this work in the first place. Faith in action to me means going to the margins of society, seeking out those who are isolated, and bringing them back in. I was putting my faith into action when I went into the field and met the women who asked me about contraceptives.

  So, yes, there is a Church teaching against contraceptives—but there is another Church teaching, which is love of neighbor. When a woman who wants her children to thrive asks me for contraceptives, her plea puts these two Church teachings into conflict, and my conscience tells me to support the woman’s desire to keep her children alive. To me, that aligns with Christ’s teaching to love my neighbor.

  Over the past decade or so, I’ve tried to get inside the mind of some of the Church’s most committed opponents of contraceptives, and I have wished they could see inside mine. I believe that if they faced an appeal from a 37-year-old mother with six children who didn’t have the health to bear and care for another child, they would find a way in their hearts to make an exception. That’s what listening does. It opens you up. It draws out your love—and love is more urgent than doctrine.

  So I don’t see my actions as putting me at odds with the Church; I feel I am following the higher teaching of the Church. I have felt strong support in this from priests, nuns, and laypeople who’ve told me that I am on solid moral ground when I speak up for women in the developing world who need contraceptives to save their children’s lives. I welcome their guidance, and it’s reassuring to me that a huge majority of Catholic women use contraceptives and believe it’s morally acceptable to do so. I also know that ultimately moral questions are personal questions. Majorities don’t matter on issues of conscience. No matter what views others may have, I am the one who has to answer for my actions, and this is my answer.

  The New Conversation—Under Way in Nairobi

  As I mentioned before, as we began planning the summit we were determined that it be focused on goals and strategy, and we ended the summit determined to make contraceptives available to 120 million more women in the sixty-nine poorest countries in the world by 2020, on the way to universal access by 2030. Those were the goals. Four years later, at the midpoint of our campaign, our data showed there were 30 million additional users of contraceptives; that meant that 300 million women overall were using modern contraceptives. The round number sounded nice, but it was 19 million below what we’d hoped.

  We had learned two important lessons by 2016. First, we needed better data. It was crucial to help us predict demand, see what was successful, and help pharmaceutical companies design products that have fewer side effects and are easier to use and cheaper to buy.

  Second, we learned again that women do not make decisions in a vacuum; they are hemmed in by the views of their husbands and mothers-in-law—and those traditions do not change easily. So along with gathering more data, we had to learn more about how our partners work in communities that might be hostile to contraceptives, and how they address the sensitive question of making contraceptives available to unmarried youth.

  To understand some of the biggest successes in these areas, I traveled to East Africa in the summer of 2016. Kenya was well ahead of its goals, and I wanted to see why.

  On my first stop, in Nairobi, I went to visit the women who gather the data. We call them resident enumerators, or REs for short. They go door-to-door in their communities, interviewing women and entering the data into their cell phones. They are trained to ask very personal questions: “When is the last time you had sexual intercourse? Do you use contraceptives? What kind? How many times have you given birth?” Most of the time, the women they interview are eager to answer. There’s something empowering about being asked. It sends a message that your life matters.

  The resident enumerators learn a lot about the lives of the respondents that they don’t really know how to turn into data. One RE told me
she went to a house where a woman lived with her husband and twelve children. The woman’s husband was opposed to family planning and turned the RE away at the door. But the mother ran into the RE later—REs live in the communities they serve—and asked her to come talk to her nine daughters when her husband wasn’t around. Unfortunately, we don’t yet know how to make the data capture the story of the controlling husband who sent the RE away.

  I saw this data challenge myself when I went to a local household with Christine, one of the REs. When she was halfway done with her survey, she handed me a mobile phone and told me to finish up. I asked the mother how many children she had, and she said two daughters. When I asked how many times she had given birth, she said three—and started to cry. She told me about her son, who died the day he was born, and then told me a painful story of her husband turning violent, beating her, and destroying all the chairs and supplies in the hair salon she had built. She took her daughter and moved in with her mother. Then she had a second daughter with another man, but she never made a reliable income, so she had trouble paying school fees and medical expenses for her daughters, and sometimes couldn’t afford to feed them.

  I was listening to this heartbreaking story, trying to enter the information in the phone, and I became frustrated that her story overwhelmed the system set up to capture the facts of her life. How did her abusive marriage affect her income? How did her income affect her use of contraceptives and the health of her children? Even if I had asked the questions, I had no place to put the answers.

  What would it take to get a more complete picture of her life? You can’t meet a need you don’t know about. I brought this question up later when I talked to the women who had gone door-to-door with me. They all nodded their heads. Every one of them had more questions they wanted to ask—about clean water, children’s health, education, domestic violence. Christine said to me, “If we could ask about domestic violence, we would be signaling to the woman that this is unacceptable behavior.” She’s exactly right, and this is an ongoing project of ours—improving data systems so we can ask more questions, gather more information, and capture the texture of women’s stories. There will never be a system that captures everything, so there will never be a substitute for hearing women’s stories. But we have to keep working to get better data so we can understand the lives of the people we serve.

  Let’s Plan

  I was also eager to visit Kenya to see a program called Tupange, a slang term for “Let’s plan.” Tupange had done a terrific job boosting contraceptive use in three of Kenya’s largest cities, and I could see why. My hosts took me to a community outreach event that had the feel of a fairground. Tupange representatives sang and danced outside to help attract foot traffic to the fair, and inside, volunteers walked around wearing giant aprons festooned with contraceptives—the most effective methods hanging at the top, the least effective methods on the bottom. There were stands offering counseling on HIV, HPV, family planning, and nutrition. It was a great way to make healthcare and family planning easy to get and stigma-free. There was a striking openness in the atmosphere and conversations—an amazing accomplishment when promoting a subject that is still in many ways taboo. Tupange has many initiatives, but each of them, in one way or another, challenges stigma and social norms. That is the key to their success.

  One of the first Tupange leaders I talked to was Rose Misati, who as a little kid was filled with dread every time her mom became pregnant. Each new baby meant more childcare duties for Rose, more chores in the home, and less time to study. She began staying home from school and falling behind her classmates. When Rose was 10, just after her mom had given birth to her eighth child, a healthcare worker came to the house, and every day after, Rose remembers her mom asking her to bring her a glass of water and one of her pills. There were no more little brothers and sisters for Rose to take care of.

  Sometimes the best thing a mother can do for her children is not have another child.

  Rose got back up to speed at school, did well on her exams, and gained entrance to the University of Nairobi. She is now a pharmacist, and she says she owes it to her mom’s family planning. So when the Tupange program asked her to help, she jumped at the chance, and became a big voice for sending community health workers door-to-door. “I know this works,” she said. “This is how they found my mom.”

  Rose knocks down stigma by the way she talks about contraceptives. When she opens meetings, she says her name, her title, and the method of family planning she uses. Then she asks others to do the same. The first time she tried it, people were shocked. Now people embrace it, and the stigma is weakening. I’ve come to learn that stigma is always an effort to suppress someone’s voice. It forces people to hide in shame. The best way to fight back is to speak up—to say openly the very thing that others stigmatize. It’s a direct attack on the self-censorship that stigma needs to survive.

  Rose weakens another stigma by reaching out to men to talk about “a women’s issue.” “When you get men on board,” she says, “their wives’ use of contraceptives is nearly universal.” She tells the men family planning will make their children healthier, stronger, and more intelligent—and because fathers see intelligent children as proof of their own intelligence, they’re open to this argument.

  Male allies are essential. It’s especially beneficial to have male allies who are religious leaders, like pastor David Opoti Inzofu. David grew up in Western Kenya with conservative parents who didn’t use family planning or discuss it. As a young man, he thought family planning was a population control conspiracy. But he started listening after he met Tupange workers who said that timing and spacing pregnancies could improve the health of the mother and child and allow families to have only as many children as they could take care of. That convinced him. Not only do he and his wife use contraceptives, but he uses his pulpit to share the message with his congregation. He points to the Bible verse 1 Timothy 5:8: “And whoever does not provide for relatives and especially family members has denied the faith and is worse than an unbeliever.”

  I was thrilled to see Tupange giving so much attention to the role men play in family planning. Men shouldn’t want to have more children than they can care for. They shouldn’t oppose women’s desire to space the births of their children. Men’s and women’s interests should be aligned, and the men who see this are the ones we want leading family planning discussions with other men.

  I met another male ally who became an advocate after an unplanned pregnancy nearly ruined his life. Shawn Wambua was only 20 years old when Damaris, his girlfriend, got pregnant. His church was on the verge of excommunicating him, his girlfriend’s family was furious with him, and he had no one to turn to—both his parents had died.

  Shawn visited a health center and learned about contraceptives. Then he asked Damaris to marry him, and she got an IUD to delay the next child until they were sure they could provide for two. Shawn then became connected with Tupange and created a group called Ndugus for Dadas (“brothers for sisters”). Every week, he leads a group of about twenty young men who talk about contraceptives and other issues they’re facing. Shawn is also taking his advocacy to the church that nearly threw him out. When church leaders spoke out against a reproductive health bill, saying that sex education would encourage promiscuity, he publicly challenged them. He believes the church is wrong to think that young people aren’t having sex or that contraceptives will give young people ideas they didn’t have before. “We share the same room with our parents,” he said. “We know what they are doing.”

  Remarkably, the church elders now allow Shawn to talk to young members of the congregation about reproductive health, as long as it’s not on church grounds. This, I think, is a perfect metaphor for the split convictions that the keepers of the old order often have. They know there is a truth on the other side that they’re not acknowledging, and while they can’t bring themselves to express that truth personally, they realize they can allow the message to be spread
by others. It’s a special experience to see when that happens, and to meet the people whose stories are so compelling that they lead the elders to soften their views.

  When social norms help everyone prosper, they have natural support because they’re in people’s self-interest. But when norms protect the power of certain groups or forbid or deny things that are a natural part of human experience, the norms can’t stand on their own; they have to be enforced by some sanction or stigma.

  Stigma is one of the biggest barriers to women’s health, and people in Tupange figured out that sometimes the best way to weaken a stigma is to defy it openly. This can be a risky strategy when the time isn’t ripe. But Tupange workers knew the culture, and they knew that their courage and defiance would force a public discussion that would expose the flaws and unfairness of the stigma. As more people challenged the stigma, there was a shift, the stigma softened, and the culture changed. This can work whether the stigma is a social norm or a national law.

  When Stigma Is Law

  Tupange shows the power of group action, but it takes individuals to bring a group into being.

  Pia Cayetano is one of those individuals. When she was elected to the Philippine Senate in 2004, there was no national law guaranteeing access to contraceptives. Local jurisdictions could do anything they wanted. Some required a prescription to get a condom. Some required pharmacies to keep a record of every contraceptive purchase. Others banned contraceptives outright. Legislators had drafted a bill to legalize contraceptives across the country, but the Catholic Church was opposed, and the bill sat idle for more than a decade.

  As a result, the maternal death rate was rising in the Philippines—even as it declined around the world. By 2012, fifteen Filipino women were dying every day in childbirth. Unlike most of her colleagues, Pia knew the wonders and dangers of childbirth. When she was pregnant with her son, Gabriel, she learned from an ultrasound that he had chromosomal abnormalities. She carried Gabriel to term and cared for him for nine months until he died in her arms. Her loss allowed her to hear with special compassion the stories of Filipino women who couldn’t get contraceptives. There was Maria, who suffered from hypertension, had three unplanned pregnancies in a row, and died during the third. There was Lourdes, who was unable to care for her eight children and had three of them taken away and given to others to raise.