In the mountains of northern Ethiopia, a man walks behind a plow, preparing his hillside land for planting. His tools and techniques are the same as those of his forefathers and mothers, stretching back to biblical times. Nearby, his children watch the family’s goats.
As he works, his wife walks 10 kilometers to wait in line for her quarterly injection of Depo-Provera. She has taken her family’s future – economic, educational, even environmental – into her own hands. She meets with a trained nurse practitioner, who monitors other aspects of her reproductive health and makes an appointment to see her in three months in the same clinic, a metal shack by the side of a muddy road.
I joined a delegation of American journalists and community activists to visit Ethiopia this fall as the guest of EngenderHealth, an international organization that provides technical assistance and training to governments, institutions and health care professionals to improve systems and services in hospitals and clinics that offer family planning and reproductive health services. We visited with doctors and nurses, professionals and volunteers, lawyers, priests, government officials and village activists, as well as the men, women and children served by these programs.
Here are the facts: Ethiopia’s population has quadrupled in the last 40 years, from under 20 million in 1966 to more than 80 million today. If present trends continue, it will reach 120 million by 2056. The increasingly depleted soil cannot provide enough food to feed its current population, and recurring natural and manmade disasters – famine, floods, HIV/AIDS, periodic political instability – regularly cause that nation to turn to the international community for crisis funding.
But use of modern birth control methods has tripled in the past 16 years. Coordinated education campaigns involving schools, non-governmental organizations, the Ethiopian government and the Ethiopian Orthodox Church are working to increase the acceptance of family planning techniques and to limit harmful traditional practices like child marriage and genital mutilation.
In addition to assistance in emergencies, the U.S. provides $432 million worldwide for international family planning. Beyond a humanitarian interest in helping impoverished people, there is a pragmatic case for American taxpayers helping Ethiopia curb its population growth rate. A country with more people than it can feed will be a constant drain on international aid. A nation that cannot afford to educate and provide employment for its young people – and 54 percent of the population is under 15 – will be unstable, and unstable poor societies breed disruption and sometimes terrorism.
U.S. involvement in the field of international family planning in the developing world is in our self-interest. But well-intentioned limitations and “strings attached” to these programs limit the impact of these taxpayer dollars. For example, under government rules, agencies receiving U.S. funds for family planning purposes – which already cannot provide abortion services – also cannot refer clients to abortion services or even offer information about abortion as a treatment option, even if the organizations use their own funds for those purposes. Thus, a service that is legal in this country cannot be even discussed in U.S.-funded facilities abroad.
In a country like Ethiopia, where 80 percent of the population lives in rural areas and women have to walk long distances for health care of any kind, requiring separate facilities for abortion care is somewhere between impractical to impossible. Many services are provided by village and market-based paraprofessionals in mobile programs. If they receive U.S. funding for any area of their programs, they cannot counsel or refer termination of pregnancy or coordinate with organizations that do. This creates an artificial isolation of reproductive health-care services that hampers their efforts at good medical practice.
The withdrawal of U.S. funding for UNFPA, the United Nations’ program for reproductive health, has been estimated to have resulted in 2 million unwanted pregnancies per year along with 800,000 abortions. This withdrawal occurred because of suspicions that UNFPA programs accommodated coercive abortion practices in China, but the effects are felt throughout the world.
One side effect of the limitation in funding is an increase in obstetric fistula, a devastating condition resulting from prolonged labor in childbirth. While fistula has virtually disappeared in the U.S. due to accessible emergency obstetric care, it is most common in areas where these services are not available, health care workers not trained to identify emergency situations, and where child marriage is prevalent.
A woman or girl with untreated fistula will be incontinent and often ostracized by her family and community. None of this is related in the least to abortion, but the cutoff of U.S. funds has made it much more difficult for UNFPA to provide preventive services and treatment of this condition, in Ethiopia as elsewhere.
Finally, the president’s African HIV/AIDS program, while unprecedented in its ambitious scope, effectively segregates family planning and AIDS prevention and treatment. It also requires that one-third of program funds be applied to sexual abstinence- related education, even though research shows that abstinence education has not been effective in reducing unwanted pregnancy or HIV. Thus, a clinic providing birth control won’t also offer HIV testing if either program is funded with these program dollars.
Current law guiding the program requires that its funded organizations oppose prostitution. The Sisters Self-Help Association provides outreach and education among sex workers along transportation routes throughout Ethiopia, provides condoms and testing, assertiveness training to encourage women in the trade to insist on protection for their clients and themselves, and options for job training and establishment in small business. But SSHA, the group arguably most on the front lines of the spread of HIV/AIDS in Ethiopia, can’t receive a dime in U.S. funding.
There is a middle ground. In many African countries, the group at greatest risk for HIV infection is married women – girls who abstained until marriage, married young and then were infected with HIV by unfaithful husbands. Proposed legislation would strike the one-third earmark for abstinence programs and allow a comprehensive and integrated prevention strategy that would address the vulnerability of these women and girls, allowing organizations to employ more effective strategies.
My visit to Ethiopia left me with indelible images of a raw and powerful landscape, strikingly beautiful, hard-working and proud people, and heroic professionals in medicine, the law and government fields working to make a better life for their country. More than anything, I remember the faces of the women and girls whose lives will be changed by decisions we make as citizens, as taxpayers and as voters.
We all should pay attention to where members of Congress and the next crop of presidential candidates stand on restrictions to federal funding for international family planning. The decisions we make as a nation help or hinder the future of Africa – and our own.
Laurie Hirshfeld Zeller is a reproductive rights and women’s leadership activist.
