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Question: What keeps you up at night?

Josh Ruxin: I guess what keeps me up at night most in Rwanda is the feat that in spite of all the efforts of really good people, expats and Rwandans over the last 15 years or so that much of the progress could actually be destroyed simply because population growth is literally out of control.  The population of Rwanda today is 10 million.  They’ve got the smallest farms in all of Africa.  They can barely produce enough food on their farms in order to feed people and the average woman still has roughly 6 children.

That means that the population in the next 18 years will go from 10 million to 20 million if it stays on its current course and so a radical shift needs to actually occur.  They need to figure out how to dramatically reduce the fertility rate down to more western levels of two, which his replacement level fertility in order to generate the economic growth that will create long term prosperity, that will mean that Rwanda will be a permanent success story.  It will not become a country that is 20 years from now, 30 years from now, still reliant on aid, but who knows.  It could become a donor country itself and that’s really the dream. 

So I stay up at night thinking to myself how are we going to get all this right if the population continues to grow at this incredible pace?  Destroying women’s lives, continuing to place enormous strains on the health system, on the education system, on infrastructure, everything you look at, the environment.  It’s all impacted by this one issue and yet this is one of the hardest issues for government of Rwanda to actually address because the church is extremely strong.  They run half the health centers in the country.  They are not huge advocates of family planning.  In many cases they do not allow family planning.  Most cases they don’t allow family planning in their health centers.  I actually have colleagues who have setup sort of satellite health centers or health posts adjacent to existing health centers where they offer family planning services.  So this is really unfortunate. 


On the positive side they have made a lot of progress.  In just the past two years the uptake of contraceptive utilization has gone from roughly 15% to 25 percent.  That’s one of the greatest leaps in contraceptive uptake in the history of humankind in any country on planet earth.  And up until now Thailand has really been the poster child of great family planning where in the 1960s their fertility rate was up around 6 and within about 25 years they’ve gotten it down to more western levels and today it’s probably approaching U.S. levels.  So how to get that done is something that provides me and my colleagues and my friends with a lot of anxiety.


The perils of population growth

Josh Ruxin:  Sadly I think if you take a look at reproductive health in general.  If you look at all the health around woman, around mothers there has been atrociously little that has happened during the past couple of decades.  I mean the major interventions that we still have today, the pill, condoms, Norplant, which today is called, which is just an injection in the arm of these slow release capsules of hormones, which prevent a woman from getting pregnant.

That’s really the last major advance that we’ve seen.  IUDs certainly, the technologies feel a little bit dated for where we are in the twenty-first century frankly.  And one of the areas where I think we’ve got to make a… take a massive leap forward is going to be in contraception, so there has been talk for example, of having some sort of ability to vaccinate a woman to not have… to not ovulate for a couple of years, so that she doesn’t have to worry about getting the pill.  She doesn’t have to worry about getting a sexually transmitted disease while she has an IUD in, which can actually be threatening to her health, but rather literally be vaccinated against ovulation.  The same can be said for men and we should have a vaccine that essentially will stop a man from producing sperm and there are a number of studies underway that are taking a look at those technologies, but that I think is what it’s going to take in order to get the uptake that we need. 

And this just isn’t Rwanda.  I mean Rwanda is very much a microcosm of the world because we feel the population pressures there.  We feel the environmental pressures, declining rainfall, huge droughts occurring, high price of food.  It really is a bit of a crucible for everything that needs to happen across all poor countries and across all poor countries family planning is one of the areas that just has not received the investment that it needs and the Obama administration would actually do rather well to look at family planning and put it back on the radar screen and make it a priority once again because you really can transform the world when you can help a woman have the number of children she desires to have and not the number of children that she essentially has no choice but to have.

Recorded on: August 13, 2009

Image: Family planning seminar in India, noborders, Flickr


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