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Gates Foundation's birth-control initiative could fire up its critics

SEATTLE -- When Bill and Melinda Gates were casting around for a cause in the 1990s, the topic that first snagged their interest was birth control. Expanding the use of contraceptives and inventing new ones seemed like a sure bet to help the worl...

SEATTLE -- When Bill and Melinda Gates were casting around for a cause in the 1990s, the topic that first snagged their interest was birth control. Expanding the use of contraceptives and inventing new ones seemed like a sure bet to help the world's poor and slow population growth.

But the world's richest couple soon had second thoughts for their nascent foundation. Within a few years, they decided to shift the focus to saving children's lives in the developing world through vaccines and cures for deadly diseases.

Now, after more than 15 years, the Gateses are returning to their charitable roots in a big way.

Earlier this year, Melinda Gates announced that she intends to put birth control back on the international agenda by making it her signature issue and significantly boosting the foundation's investment. On Wednesday, the Gates Foundation and the British government will convene a summit of world leaders in London with the goal of raising $4 billion to make contraceptives available to an additional 120 million women in the poorest countries.

The move puts the Gates Foundation on a collision course with the Catholic Church and elements of the religious right. A Catholic herself, Melinda Gates is attempting to defuse the controversy by framing her crusade in terms of health and individual choice. In her travels around the world, she has said, reliable supplies of contraceptives are among the things poor women ask for most.


"We're not talking about abortion. We're not talking about population control," Melinda Gates said in the Berlin TEDxChange talk where she kicked off her initiative in April. "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."

The foundation set up a website called No-Controversy.com, asking people to share personal stories about birth control and pledge support for the effort. Melinda Gates even appeared on Comedy Central's "Colbert Report" last month, laughing when faux-conservative Stephen Colbert warned against turning the Seattle foundation into a "slut factory."

Veterans of the birth-control wars agree the foundation could be in for a harsher brand of criticism than it has faced in the past.

The fear of becoming a target in America's culture wars was one of many reasons the foundation backed away from birth control in the early days, and some insiders remain justifiably worried about the PR fallout, said Steven Sinding, former director general of the International Planned Parenthood Federation and one of a small cadre of experts who never stopped urging the Gates Foundation to take up the cause again.

Catholic blogs and anti-abortion websites like LifeSiteNews have already branded Melinda Gates a Judas to her faith and accused her of mounting a "blatant attack on Catholic sexual morality."

But given the wide support for birth control around the world, even among many Catholics, the foundation should be able to weather the storm as long it continues to make it clear it does not support abortion, said Duff Gillespie, a family-planning expert at Johns Hopkins University.

Even after shifting its focus to vaccines and disease, the Gates Foundation continued to spend an average of $30 million a year on family-planning programs. And in his first annual letter on the foundation's work, Bill Gates explained that boosting child survival will lead to a drop in birthrates, as parents see more of their children live to adulthood.

Gates' statements inspired a reply from Sinding and several others, who jointly composed a letter pointing out that improvements in child survival will, indeed, nudge birthrates down -- but that the shift can take decades if people don't have access to contraceptives.


The Gates Foundation responded courteously to that first letter, Sinding recalled. "We interpreted that as a polite kiss-off."

But after a second letter, which pointed out the many health benefits to women and children of spacing pregnancies and limiting family size, the foundation reached out for more information. Family-planning veterans were also invited to brief Bill Gates and his staff and, most recently, Melinda Gates.

She bowled the old hands over with her penetrating questions and grasp of the issues, Gillespie said. "We just came away unbelievably impressed."

In her TED talk, Melinda Gates describes more emotional encounters with women in Africa, who often walk miles to the nearest clinic only to find the three-month injectable contraceptives they prefer are out of stock. She said she was particularly moved by a group of women at a Kenyan slum, one of whom said she wanted to avoid getting pregnant again in order to bring "every good thing" to her newborn.

Kenyan-born Musimbi Kanyoro, CEO of The Global Fund for Women, said Gates' observations mirror her own. "The women in the developing world have the same desires as women in the West," she said. "This is about people making decisions for themselves."

The United Nations estimates more than 200 million women in the developing world want to avoid pregnancy but lack access to contraceptives.

If the London summit raises enough money to reach 120 million women, that would translate into 100 million fewer unwanted pregnancies and 200,000 fewer maternal deaths, said Gary Darmstadt, head of family health at the Gates Foundation. Every dollar invested in family planning returns six dollars to a country's economy through health care and other savings, he added.

The foundation also estimates greater access to contraceptives could avert 50 million abortions between now and 2020. That doesn't include the spontaneous abortions that are common among African women who get pregnant too young or too often, Kanyoro said. Her own mother-in-law bled to death when she suffered a miscarriage during her fifth pregnancy.


Sharing women's stories may help garner support in the developed world, but to get Africa's top leadership on board will take economic persuasion, said John Cleland, a family-planning expert at the London School of Hygiene and Tropical Medicine.

"What African prime ministers and presidents get excited about is reducing poverty and hunger," Cleland said.

Slowing population growth can provide an economic jump-start, as it did for many Asian countries, by setting the stage for several generations when working adults far outnumber children and the elderly, he said. "If I was going to talk to a president or minister of finance in Africa, that's the argument I would make."

The Gates Foundation does bring economics into the equation, but couches it in terms of benefits to families who find it easier to feed and educate fewer children. A long-running study in Bangladesh showed that communities given easy access to contraceptives were healthier and more prosperous a decade later, Darmstadt said.

One word Gates Foundation folks never utter is "overpopulation" -- likely in order to distance its initiatives from the heavy-handed approaches of the past.

It was a concern over runaway growth -- and the specter of revolution in the developing world -- that made global birth control a top U.S. priority in the 1950s and '60s. Many good programs resulted, but there were also abuses, like the forced sterilization of poor women in India, Peru and even the southern United States. China's coercive one-child policy added to a growing backlash against family planning.

In the 1980s, the AIDS epidemic consumed health budgets, and the fortunes of birth-control programs continued to decline. When America's religious right pushed through policies to block funding for programs that even mentioned abortion, many voices in support of family planning were effectively silenced, said Jane Hutchings, director of reproductive health at the Seattle-based nonprofit Path.

"People feared that if they spoke out, there would be consequences."


Despite steep cuts in family-planning budgets over the past decade, population growth has leveled out in much of the world. In 1950, the average woman gave birth to five children. Today, the global average is 2.4. Most of the countries that lag are in sub-Saharan Africa, where contraceptive use remains low.

One of the Gates Foundation's top priorities will be to improve the distribution of contraceptives, so that women won't encounter empty shelves, Darmstadt said. In Senegal, a Gates-funded pilot project helped clinics evaluate their needs and set up a new ordering system that ensures adequate supplies. The next step will be to scale it up, Darmstadt said.

Under another Gates grant, Hutchings and her colleagues at Path created an international coalition of countries, donors and pharmaceutical companies that has already lowered prices for contraceptive implants.

The foundation will also fund research on new contraceptives, Darmstadt said. Among the possibilities are longer-lasting implants and shots women can give themselves.

The foundation is keeping mum on the level of new funding Melinda Gates will announce at the London summit. With an endowment of more than $30 billion, the philanthropy has pledged $1 billion a year for childhood vaccines, its top priority. Observers don't expect to see numbers like that for family planning, but do anticipate a sizable bump.

The foundation's most valuable contribution may be its willingness to stand up for the long-neglected cause, Sinding said.

"The fact that the Gates Foundation is not only providing financial support but also speaking out on the importance of family planning has an influence way out of proportion to the amount of money they provide."

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