Let's put birth control back on the agenda - Melinda Gates

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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.

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 make act on their decision.

Now, I think you'd have a hard time finding many people who disagree with this idea. Over 1 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.

Now, 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. But these are all side issues they've attached to this core idea that men and women should be able to decide when they want to have a child.

As a result, birth control has almost completely and totally disappeared from the global health agenda, and 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%. That's about what you'd expect in El Salvador—very similar, 66%. Thailand, 64%.

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%. Nigeria, the most populous country in Africa: 10%. Chad: 2%. So, let's just take one country in Africa, Senegal; their rate is about 12%.

But why is it so low? Well, 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 that 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. 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 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 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.

Now, 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—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.

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 school teacher and a principal her entire life. In fact, she's the one that 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. And today, in the 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. 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.

I think it'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, off the porch at home, they said, "Even though you've had this great education, if you decide to get married and have kids right away, that's okay by us too."

They wanted me to do the thing that would make me the very happiest, and 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. So now Bill and I have three. 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. So we waited a little while before we had our second child.

You know, 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.

What has struck me as I've traveled 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 "standing shoulder to shoulder." 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 spoke quite intimately about what they did for birth control.

MaryAnn, who's in the center of this screen in the red sweater, 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."

I thought, "That's it—it'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 the basic education, but even many of the women who do have knowledge and they do have power don't have access to contraceptives.

You know, 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.

You know, 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 towards 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.

In France, the average family size went down every decade for 150 years in a row until it stabilized. It took so long back then because the contraceptives, frankly, weren't that good. In Germany, this transition started in the 1880s and it took just 50 years for family size to stabilize in this country.

In Asia and Latin America, the transition started in the 1960s and it happened much faster because of modern contraception. But I think as we go through this history, it's important to pause for a moment and to remember why this has become such a contentious issue.

It's because some family planning programs resorted to unfortunate incentives and coercive policies. For instance, in the 1960s, India adopted very specific numeric targets and they paid women to accept having an IUD placed in their bodies. Now, Indian women were really smart in this situation. When they went to get an IUD inserted, they got paid six rupees. And so what did they do? They waited a few hours or a few days, and they went to another service provider and they had the IUD removed for one rupee.

For decades, in the United States, African-American women were sterilized without their consent. The procedure was so common it became known as the "Mississippi appendectomy"—a tragic chapter in my country's history. And as recently as the 1990s, in Peru, women from the Andes region were given anesthesia and they were sterilized without their knowledge.

The most startling thing about this is that these coercive policies weren't even needed. They were carried out in places where parents already wanted to lower their family size. Because, in region after region, again and again, parents have wanted to have smaller families. So there's no reason to believe that African women have innately different desires. Given the option, they will have fewer children.

The question is, will we invest in helping all women get what they want now, or are we going to condemn them to some century-long struggle as if this was still revolutionary France and the best method was coitus interruptus? Empowering parents doesn't need justification, but here's the thing: our desire to bring every good thing to our children is a force for good throughout the world.

It's what propels societies forward. In that same slum in Nairobi, I met a young businesswoman, and she was making backpacks out of her home. She and her young kids would go to the local jeans factory and collect scraps of denim. She'd create these backpacks and resell them.

When I talked with her, she had three children, and I asked her about her family. She said she and her husband decided that they wanted to stop having children after their third one. When I asked her why, she simply said, "Well, because I couldn't run my business if I had another child."

She explained the income that she was getting out of her business afforded her to be able to give an education to all three of her children. She was incredibly optimistic about her family's future.

This is the same mental calculus that hundreds of millions of men and women have gone through, and evidence proves that they have it exactly right. They are able to give their children more opportunities by exercising control over when they have them.

In Bangladesh, there's a district called Matlab. It's where researchers have collected data on over 180,000 inhabitants since 1963. In the global health community, we like to say it's one of the longest pieces of research that's been running. We have so many great health statistics.

In one of the studies, what did they do? They gave half the villagers access to contraceptives and education. Twenty years later, in following those villages, what we learned is that they had a better quality of life than their neighbors.

The families were healthier, the women were less likely to die in childbirth, their children were less likely to die in the first 30 days of life. They were better nourished. The families were also wealthier. The adult women's wages were higher; households had more assets—things like livestock or land or savings—and finally, their sons and daughters had more schooling.

So when you multiply these types of effects over millions of families, the product can be large-scale economic development. People talk about the Asian economic miracle of the 1980s, but it wasn't really a miracle. One of the leading causes of economic growth across that region was this cultural trend towards smaller families.

So sweeping changes start at the individual family level—the family making a decision about what's best for their children. When they make that change and that decision, those become sweeping regional and national trends.

So when families in Sub-Saharan Africa are given the opportunity to make those decisions for themselves, I think it will help spark a virtuous cycle of development in communities across the continent. We can help poor families build a better future.

We can insist that all people have the opportunity to learn about contraceptives and have access to the full variety of methods. I think the goal here is really clear: universal access to birth control, control that women want.

For that to happen, it means that both rich and poor governments alike must make contraception a total priority. We can do our part in this room and globally by talking about the hundreds of millions of families that don't have access to contraception today and what it would do to change their lives if they did have access.

I think if MaryAnn and the members of her women's group can talk about this openly and have this discussion among themselves and in public, we can too. And we need to start now, because like MaryAnn, we all want to bring every good thing to our children.

And where is the controversy in that? Thank you, thank you.

So, I have some, um, I have some questions—some questions for Melinda. Um, thank you for your courage and everything else.

So, Melinda, in the last few years I've heard a lot of smart people say something to the effect of, "We don't need to worry about the population issue anymore. You know, family sizes are coming down naturally all over the world. We're going to peak at 9 or 10 billion, and that's it." Are they wrong?

Well, if you look at the statistics across Africa, they are wrong. And I think we need to look at it, though, from a different lens. We need to look at it from the ground upwards. I think that's one of the reasons we got ourselves in so much trouble on this issue of contraception is we looked at it from top down and said we want to have different population numbers over time. Yes, we care about the planet. Yes, we need to make the right choices. But the choices have to be made at the family level.

And it's only by giving people access and letting them choose what to do that you get those sweeping changes that we have seen globally, except for Sub-Saharan Africa, except for those places in South Asia and Afghanistan.

Some people on the right in America and in many conservative cultures around the world might say something like this: they might say it's all very well to talk about saving lives and empowering women and so on, but um, sex is sacred. Um, what you're proposing is going to increase the likelihood that sex happens outside marriage, and that is wrong. What would you say to them?

I would say that sex is absolutely sacred, and it's sacred in Germany, and it's sacred in the United States, and it's sacred in France, and so many places around the world. And the fact that 98% of women in my country who are sexually experienced say they use birth control doesn't make sex any less sacred. It just means that they're getting to make choices about their lives.

And I think in that choice, we're also honoring the sacredness of the family and the sacredness of the mother's life and the children's life by saving their lives. And to me, that's incredibly sacred too.

So what is your foundation doing to promote this issue, and what could people here and people listening on the web, what would you like them to do?

Well, I would say this: join the conversation. We've lifted the website up here. Um, join the conversation. Tell your story about how contraception has either changed your life or somebody's life that you know, and say that you're for this.

We need a groundswell of people saying this makes sense. We've got to give all women access no matter where they live. One of the things that we're going to do is do a large event in July—July 11th in London—with a whole host of countries, a whole host of African nations, to all say we're putting this back on the global health agenda.

We're going to commit resources to it, and we're going to do planning from the bottoms up with governments to make sure that women are educated so that if they want the tool, they have it, and then they have lots of options available, either through their local health care worker or in their local community rural clinic.

Um, Melinda, I'm guessing that some of those nuns who taught you at school are going to see this Ted Talk at some point. Are they going to be horrified, or are they cheering you on?

Well, I know they're going to see the Ted Talk because they know that I'm doing it, and I plan to send it to them. You know, the nuns who taught me were incredibly progressive, and I hope that they'll be very proud of me for living out what they taught us about social justice and service.

I have come to feel incredibly passionate about this issue because of what I've seen in the developing world, and for me, this topic has become very close to heart because you meet these women, and they are so often voiceless. And yet they shouldn't be. They should have a voice; they should have access.

And so I hope they'll feel that I'm living out what I've learned from them and from the decades of work that I've already done at the foundation.

So you and your team brought together today an amazing group of speakers to whom we're all grateful. Did you learn anything from...

Oh my gosh, I learned so many things that have so many follow-up questions, and I think a lot of this work is a journey. You heard the discussion about the journey through energy or the journey through social design or the journey coming to and saying, "Why aren't there any women on this platform?"

I think for all of us who work on these development issues, you learn by talking to other people. You learn by doing. You learn by trying and making mistakes, and it's the questions you ask—sometimes it's the question you ask that helps lead to the answer the next person that can help you answer it.

So I have lots of questions for the panelists from today, and I thought it was just an amazing day. Linda, thank you for inviting all of us on this journey with you.

Thank you so much. Great thanks, Chris.