In Bolivia, smaller families spur higher hopes
This report continues a series, begun on Jan. 26, on world health challenges and the solutions that are within reach.
EL ALTO, Bolivia -- Patients flowed steadily into the gleaming health clinic in this slum on the mountainous fringe of the Bolivian capital. Each person had a story.
Yolanda Sahire, 36, a part-time secretary, had come for her regular birth control injection. With three children, she has decided her wages will support no more.
Juan Lecona Apaza, 28, spoke proudly of his recent vasectomy. He has two sons and earns a modest salary as a tailor. He'd heard about the clinic from a radio ad. "We decided not to have any more children because I don't have regular work," he said.
And then came Beatriz Silva, a 23-year-old who sells cheap kitchenware in a nearby market. She has two children -- and a burning concern. She had just missed her period.
"I have no money to support children," she tells a doctor.
Three people. Three stories. All part of a larger tale transforming the developing world.
Throughout the year, the Globe has been chronicling the millions of lives lost every year in poorer nations -- the needless victims of preventable diseases. Many outside the developing world, confronted with this staggering toll, ask: Why won't the poor help themselves by having fewer children?
In Bolivia and many other countries, they are. Far fewer.
In a largely unheralded trend, birth rates in developing countries around the world have declined steadily over the last several decades, thanks to economic growth, urbanization, medical improvements, and expanding educational opportunities. Aggressive and imaginative population control programs have been critical to changing local lifestyles. As a result, the world's population is growing far more slowly than it would have had the birthrates of the 1950s not been curtailed.
In Bolivia, for example, mothers in 1970 had an average of 6.5 children. Last year it was 3.9 children, and demographers predict further declines in coming years. Fertility rates have also been falling in the majority of developing countries, among them India, Pakistan, Nigeria, China, Bangladesh, and Ethiopia.
In some nations growth rates have only eased. In others they have been reversed: Some 33 nations will actually shrink in population, including the former Soviet states. By 2050, three of every four developing nations will have stabilized their populations, according to the latest United Nations forecast.
The decline in birthrates has profound and hopeful implications, economists and demographers agree, for human welfare in dozens of nations long beset by too many people to feed, house, govern, employ, and care for.
"Conventional wisdom did not foresee this decline," said Joseph Chamie, director of the UN's population division. "It's stunning. Rates are coming down in India, Africa, Latin America, the Caribbean."
Laboratory of change
The well appointed clinic near the Bolivian capital of La Paz is a laboratory for this transformation. Comanaged by Engender Health, a New York-based nonprofit, and the Center for Education, Research, and Services, a Bolivian nonprofit group, the clinic employs 10 Bolivian doctors who aggressively promote birth control and perform surgical sterilizations, in addition to other basic health services.
Beatriz Silva is one whose life was changed by their work.
The Silva family lives in El Alto, a slum of more than half a million people. Like most of their neighbors, they were driven by poverty and disappearing farm jobs to move here from a rural section of this mountainous South American country. Two-thirds of Bolivians now live in urban areas, where, without farms to work and with living space tight, the incentive is strong to have fewer children.
Silva grew up as one of six children. She wants to stop at two.
In farm country, more children provide extra hands in the fields. But in the city, they can be an economic drain. "I cannot feed more," she said.
Another change: Silva is a high school graduate, the first woman in her family to reach that milestone. More and more Bolivian women are attending schools, where, in addition to academic subjects, they are taught about birth control. Government statistics show that knowledge of modern contraception methods among Bolivians jumped from 68 percent in 1989 to 86 percent a decade later.
Better educated women are also more likely to seek work over perpetual parenting. Silva feels this way. She is a dreamer, who imagines a better life for herself and her family. Though her experience is limited to life in northwestern Bolivia, her mind often wanders far and wide. She asked a recent visitor with wonder: "Have you really seen the ocean?"
But when she walked into the clinic early one morning in July, she knew there was no room left for wondering. She needed a pregnancy test.
After paying a nominal fee, she was pricked with a needle, drawing blood. Minutes later, Silva triumphantly held aloft a tiny white slip: "Resultado: Negativo."
She was not pregnant. Breastfeeding her daughter probably disrupted her period, the nurse said.
About an hour later a doctor fitted her with an intrauterine birth control device, and later quipped: "Why don't you give it a try tonight!"
Startling global numbers
Despite the common belief that population explosion must lie behind disease and suffering in many countries, demographers have long been aware of the developing world's fertility decline.
Five decades ago, women in the developing world had an overall fertility rate of 6, meaning that, on average, six children were born to each woman of childbearing age. A fertility rate of 2 is considered stable -- two parents replaced by two children. Rates above 2 indicate a nation's population will grow; below that portends shrinkage. The rate in the United States is 2.1.
In developing nations generally, average fertility rates are down to just over 3. And the most respected world population forecast, released earlier this year by the UN, predicts the rate will continue its gradual decline.
The report predicts that, by 2050, three of every four developing nations will have fertility rates of 2.1 or less. Many of these nations -- among them Albania, Colombia, Mongolia, and Sri Lanka -- will cross the threshold by 2035.
The world's population will grow 2.6 billion over the next 50 years to 8.9 billion, according to UN forecasts. The total would have grown to 12.8 billion in the same period had fertility rates not decreased.
But in a small number of nations, some of them among the world's poorest, the population trend continues to spiral upward. In Burkina Faso, Mali, Niger, Somalia, Uganda, and Yemen, the population is expected to quadruple in the next half-century, driven by poverty, dysfunctional governments, and broken or nonexistent educational systems. And those countries nearing fertility rates of 3 still have a long way to go to achieve stability.
"It's not easy to get to 2," said John Bongaarts, of the nonprofit Population Council. "Some of these countries will stay stuck at 3. Getting from 3 to 2 sounds easy, because you've gotten down from 6."
But all experts interviewed said global population trends are moving the right direction.
Said the UN's Chamie, who oversaw the study: "It's good news. People are living longer, and people are more able to control the number and spacing of their children. This is really a success story."
Success in Bolivia
Where success has been most pronounced -- from population control pioneer Mexico in the 1960s to Bolivia today -- a critical factor has been a nation's determination to change cultural norms. Bolivia's government has taken an active role in furthering the fertility decline here, often bucking powerful opponents of social change.
This landlocked nation is about three times the size of Montana, with rugged Andes peaks and high-altitude plains in the west and tropical lowlands in the east. About 55 percent of the population are Quechua or Aymara, indigenous ethnic groups. The rest of the country is white or mixed race.
Bolivia is among the least prosperous of Latin American countries, with a $21 billion economy that has scarcely grown in the last decade. Three-fourths of Bolivians live in poverty, surviving on less than $2 per day.
Such economic hardship has fueled unrest here. In October Bolivian protesters stormed La Paz to challenge the government's attempts to build a pipeline to sell the nation's supply of natural gas abroad. More than 60 protesters were killed, and Bolivia's democratically elected president resigned. His successor continues to face considerable pressure from protest groups, who threaten further protests if conditions for rural farmers and peasants do not improve.
The nation's two-decade-old family-planning effort was conceived, in part, to alleviate the economic pressures that have led to this sort of chronic political instability.
"They see themselves as the least developed country in Latin America, and they wanted to rise above that," said Dr. Amy Pollack, Engender Health's president.
The population control program took root in spite of the powerful influence of the Catholic Church here, and rampant suspicion about foreign meddling in local affairs. This is a country where, 20 years ago, politics were dominated by rumors that US Peace Corps volunteers were forcibly sterilizing peasants. This led the church and labor movements, under the banner of anti-imperialism, to actively oppose family-planning efforts, forcing the government to back off.
But in 1986 Bolivian health bureaucrats, facing a rapidly growing population, and under pressure from the UN, decided to get active again. They began a quiet effort to train doctors in surgical sterilizations under the guise of a program to reduce abortion -- illegal but common -- in order to keep the church at bay.
In 1995 the effort went aboveground when the government announced that family-planning expertise would be mandatory for all hospitals and clinics. Hospitals would have to offer sterilization surgery, and clinics would be required to stock IUDs and condoms. The policy was reaffirmed in 1999, when every Bolivian health worker was given a 73-page manual on the basics of family planning, including tips on how to discuss the issue with patients.
"Right now, the church isn't a problem because the government has established the family-planning rules and policies," said Dr. Miguel Ugalde Castro, a government-employed obstetrician who works at several La Paz hospitals.
The drive has yielded remarkable results: Over the last three decades, Bolivia's fertility rate has dropped by more than a third. Further declines are predicted.
Sweeping historical forces
It isn't just a shift by the government that has propelled the change. There has also been a profound change at ground level: Increasingly, in the developing world, big families no longer make economic sense.
Farming has long supplied the most gainful work in poor nations. Extra hands can harvest more. But in the last few decades, manufacturing and service jobs in many of these countries have boomed, while agricultural employment has declined.
And so people moved to urban areas, following the new industrial jobs. According to a 2001 UN report, the percentage of the world's population living in cities will rise to 60 percent by 2030 from 30 percent in 1950.
Urbanization has brought a host of changes. To secure industrial jobs, parents increasingly send children, including many more girls, to school. And more women have entered the work force.
"Educated women want educated children," said Bongaarts, who noted that research demonstrates a strong positive correllation between a mother's education level and the likelihood her children will get schooling.
And educated women, the data clearly show, tend to have fewer children. In Brazil, for instance, illiterate women have a 6.5 fertility rate, while those with secondary schooling have a rate of 2.5.
This fertility trend, however, does not extend as dramatically to rural Bolivia, where a shrinking but still sizable portion of the country's populace dwells. In Bolivia's urban areas, the overall fertility rate is 3.6; in rural areas, it is 6.2.
The difference is readily apparent. One day last July, Engender Health obsterician Dr. Silvia Vargas returned from a training mission in the Pando province of Bolivia, a poor region in the nation's northernmost tip. Residents survive by growing corn, coffee, rubber plants, and chestnuts for export to Brazil. The fertility rate there is 7, unchanged for decades.
Vargas had gone to train local doctors in family-planning methods, as well as help with patients. The experience left her drained: Her lessons on family planning fell on deaf ears; mothers insisted more children were needed to help in the fields.
"Sometimes the local governments in those areas are weak on family planning," Vargas said. "There are still some problems in getting doctors out there to get motivated about family planning.
"Women need space to grow, to realize themselves," she said. "They can't be mothers all their lives."
A better life
The payoff in economic growth could be enormous for Bolivia and other developing nations.
"Having fewer children means greater investment in each child," said Robert Jensen, an economist at Harvard's Kennedy School of Government. "More education, more health care, and more attention paid to each child."
Economists refer to the benefits of fertility decline as the "demographic dividend."
South Korea's transformation into an industrial powerhouse over the last few decades was driven, in part, by favorable demographics.
"The economies of China and India are now roaring ahead, and a great deal of this has to do with demographics," Chamie said.
All the societal trends sweeping Bolivia come alive in Clorinda Imana de Toro, 35, who walked into the El Alto clinic one day this past July. She has three children -- two of them born when she was a young woman. Imana de Toro, the daughter of a poor family that migrated to the slum from rural parts, graduated from high school, then attended a teachers' academy.
She now teaches elementary school in El Alto. She and her husband are saving money to move down into La Paz, where she can see gleaming office towers from her home in El Alto. Then, three months ago, she became pregnant again.
She joked, "In El Alto, we are rich -- but only in children."
But she took it seriously, concluding that having more children would ruin her cosmopolitan ambitions.
So she had doctors fit her with an IUD, and walked out of the clinic, into the midday sun.
"I want a better life," she said.
Raja Mishra can be reached at rmishra@globe.com. 