Six Billion-Growing Population and Sustainable Development: Will Population Issues Undermine the Achievement of the Millennium Development Goals and Poverty Reduction?

Thank you, Mr. President, for your kind invitation. It is both an honour and a pleasure to be here today at the World Bank to participate in the annual Presidential Lecture series. Through you, I and my UNFPA colleagues who have accompanied me for this visit, would like to thank each one of our friends at the World Bank for welcoming us so warmly and for making arrangements for the visit to this gigantic institution.

First of all, I would like to express my admiration to you, Mr. President, for your stewardship of the Bank and your visionary leadership in focusing the Bank's attention and resources on the reduction of poverty as well for advocating that culture counts.

Mr. President, I will argue today that population and reproductive health issues also count because they are the direct and/or indirect underpinning for the achievement of the Millennium Development Goals (MDGs). By giving greater policy attention and generating much more resources to population and reproductive health issues, we will actually make greater progress to reduce poverty, maternal and child mortality, halt the spread of AIDS, increase gender equality and equity and ensure sustainable development, as world leaders agreed at the Millennium Summit. If we put aside the debate and the different interpretations of reproductive health, we will find that, from a human rights and also a pragmatic point of view, seven of the MDGs cannot be achieved, either directly or indirectly, without taking population policies seriously and ensuring that universal access to reproductive health services is attained.

A Human Centred Approach-ICPD

The challenge we all face together is to reduce the severe poverty that afflicts 1.2 billion people today and to create the conditions to enable the 1 billion people that will be added to world population by 2015, when we are expected to achieve the Millennium Development Goals, to live free of poverty-or as the Millennium Declaration said-to live free from want. This is a tremendous challenge because population is growing fastest in the poorest countries-many of which are suffering from environmental degradation, food and water shortages, and HIV/AIDS.

To effectively address these issues, we need a comprehensive, well-coordinated global strategy that has a human heart and spirit. And I strongly believe that the consensus that was achieved in Cairo at the 1994 International Conference on Population and Development is part of this global strategy and is visionary in its own right. It looked forward and recognized the basic requirements to achieve development of individuals and societies. This was further expanded by the agreement reached at the United Nations General Assembly Special Session in 1999, which adopted, also by consensus, the key actions for further implementation of ICPD. These two documents include goals and benchmarks that informed the formulation of the MDGs in one way or another.

We know from ICPD that diverse population issues-including population growth, location, age distribution and migration, and their evolving dynamics-must be integrated in the development process. Most critically, we also know that the Cairo Conference moved the discussion on population away from numbers and targets, to a focus on women's rights as human rights. These rights include the right of every woman and couple to determine the number, spacing and timing of their children, and to make decisions concerning reproduction free of discrimination, violence and coercion. Perhaps most importantly, the Cairo Conference recognized the importance of empowering women so they can make their own choices and participate more fully in all aspects of society.

UNFPA provides support to 142 countries, at their request, to address reproductive health and population issues and raises awareness of these issues. We have three main areas of work: to help ensure universal access to reproductive health, including family planning, to all couples and individuals on or before the year 2015; to support population and development strategies that enable capacity-building in population programming; and to promote awareness of population and development issues and advocate for the mobilization of the resources and political will necessary to accomplish these areas of work.

UNFPA affirms its commitment to reproductive rights, gender equality and male responsibility, and to empowerment of women everywhere. We believe that safeguarding and promoting these rights, and promoting the well-being of children, especially girl children, are development goals in themselves. We are convinced that meeting these goals will contribute to improving the quality of life and to the universally accepted aim of stabilizing world population. We also believe that these goals are an integral part of all efforts to achieve sustained and sustainable social and economic development that meets human needs, ensures well-being and protects the natural resources on which all life depends-in other words to achieve the Millennium Development Goals.

As I said before, this is a visionary agenda-one that is rooted in the concepts of human rights and sustainable development-and one that deserves far greater support as we mobilize to achieve the Millennium Development Goals.

Population has historically been the most divisive social issue on the United Nations agenda. Of course, it is, and always will be, a very sensitive issue, but we do have a solid working consensus and we need to stay on track. The Cairo consensus is working in many countries that are incorporating gender, reproductive health and population dynamics into their national development plans. For example, today, Iran is running a highly successful, highly popular, comprehensive population and reproductive health programme firmly based on international principles of choice. As a result, fertility rates have dropped by half in the last decade. Brazil has abandoned its laissez-faire approach to family planning and is now adopting a reproductive health approach, which will save many women's lives.

Women in large numbers in all parts of the world are choosing to have smaller families and this has caused population growth to slow, thus impacting positively on poverty reduction. Overall, the story of population is a success and it will continue to be a success if we stay focused and committed to population and reproductive health and if we provide the necessary institutional support and financial resources for these programmes.

Population and Poverty

We now have solid evidence, based on research by Steven Sinding, Nancy Birdsall, Tom Merrick and others, that work towards population goals helps reduce poverty in several ways-both at the household and national levels.

At the national level, it is becoming increasingly clear that slower population growth encourages overall economic growth. The best recent macro-level research suggests that from 1960 to 1995, about a fifth of economic growth is attributable to reductions in mortality and about a fifth to reductions in fertility. Evidence also suggests that successful emerging economies almost always have favourable demographics.

In fact, the World Bank-supported project Voices of the Poor vividly illustrates how poor people themselves view poverty. In Ghana, for instance, it was found that poor men and women considered lack of money, unemployment, and having too many children as leading causes of poverty. They often spoke of their large households and the added stress this often places on meagre resources and social relations. Many women and men included "unplanned births", "lack of family planning", or "too many children" among the causes of poverty.

It is clear that poor health, illiteracy, inadequate schooling, social and economic exclusion and gender discrimination contribute to poverty. It is widely acknowledged that poor health diminishes personal capacity, lowers productivity and reduces earnings. Furthermore, a high prevalence of disease and poor health in a country harms economic performance while higher life expectancy, a key indicator of health status, stimulates economic growth. This is one of the main outcomes of the WHO Commission on Macroeconomics and Health.

Yet today, despite the international goal of universal access to reproductive health as adopted at the Cairo Conference and despite the persistent poor reproductive health which remains a leading cause of death and disability for women and children in the developing world, there is still reluctance, to say the least, to reflect properly this goal among the MDGs or even use a related indicator. This has a tremendous social and economic cost and this is hindering progress in achieving key MDGs such as reducing maternal and child mortality, and reversing the spread of HIV/AIDS.

Maternal Mortality

Mr. President, please allow me to examine first the issue of maternal mortality. Today more than half a million women die each year from complications of pregnancy and childbirth-almost all in developing countries-even though we know what needs to be done to reduce maternal deaths. We know that women need access to family planning so they can better plan and space their births. We know that all women need prenatal care during pregnancy, and skilled attendants at birth. And we know, and this was a hard lesson to learn, that pregnant women need access to emergency obstetric care if complications arise. It is estimated that half a million women die from complications of pregnancy and child birth and another 15 to 30 times that number suffer from serious complications. Yet, today only 58 per cent of women in the developing world give birth with a trained attendant. This is more than neglect. This is a public health failure that is unconscionable in an era of unprecedented wealth and technology. Giving birth, which is supposed to be the most natural and most joyous experience, should never send women to their death.

Fortunately, we know that progress can be achieved. For example, Tunisia reduced its maternal mortality rate by 80 percent in 23 years with a comprehensive strategy emphasizing skilled attendants at delivery. Similarly, Sri Lanka reduced its maternal mortality rate from more than 1,500 per 100,000 live births to 30 today.

Working together, we must replicate these successes in all countries where the rates of maternal mortality remain high. The worldwide economic impact of maternal mortality has been estimated by USAID as $7.5 billion annually in diminished potential productivity of the women who die, and an estimated $8 billion in diminished potential productivity of the newborns that do not survive.

Child Mortality

Investment in family planning, as part of an integrated package of reproductive health services, is one of the most cost-effective investments in the development package. In addition to enabling couples to determine their family size, and giving women control over their fertility, family planning offers another concrete benefit. Family planning saves the lives of mothers, babies and children. In Costa Rica, for instance, the government's commitment to family planning services has helped lower the infant mortality rate by 80 per cent. Family planning also lowers the mortality rates of children under the age of 5. Evidence has consistently shown that waiting two years between births gives infants and children through age 5 a better chance of survival. Now, a new report by Johns Hopkins University has found that waiting even longer-three to five years-between births is even better. So it is clear that reproductive health services, including family planning, play a significant role in the achievement of the goal of reducing child as well as maternal mortality.

HIV/AIDS

However, Mr. President, one of the strongest reasons for greater investment in reproductive health is to reduce the spread of HIV/AIDS. AIDS is taking a brutal toll everywhere it strikes, particularly in southern Africa and increasingly in parts of Asia, Eastern Europe and the Caribbean. Despite the havoc and damage it has already caused, experts estimate that the pandemic is still in its early stages.

We all know that the response to AIDS has not been sufficient. We know this because the HIV virus continues to spread. As we work on supporting programmes, we need to remind ourselves of the dark shadow that HIV/AIDS pandemic has cast all over the world and thus the urgency of our collective responses. In Africa, life expectancy has fallen by between 18 and 23 years in the worst-affected countries; malnutrition has risen; immunization rates have dropped; 14 million children have been orphaned, and 4 million children have died of AIDS since the epidemic began. The actual demographic outcome has yet to be calculated, but we do know that the one country that had actually managed to graduate from the list of least-developed countries, Botswana, is now facing an economic and social crisis of unprecedented proportions. Having the sad distinction of being the country with the highest HIV prevalence, with about one in three adults infected, life expectancy has dropped from 60 years a decade ago to 36 years today. Hitting adolescents and youth hardest, Botswana's population is projected to be 28 per cent smaller in 2015 than it would have been without HIV/AIDS.

In all heavily affected countries, the death of teachers and health workers from AIDS is wreaking havoc on social services that are crucial to welfare and development. This is amplified in the example of Botswana. It has also recently become apparent that the growing famine across southern Africa, putting 14 million people at risk of starvation and presenting one of the gravest humanitarian crises in recent memory, is exacerbated by HIV/AIDS, which is causing agricultural productivity to decline, forcing children to drop out of school, and placing an extraordinary burden on families and health systems. At the same time, famine, leading to loss in nutrition, is in turn giving HIV/AIDS a free reign over the lives of the devastated people. It is safe to say that governments that fail to respond with comprehensive large-scale national programmes and international support are not only facing the prospect of millions of sufferers but of the very fabric of their societies coming unravelled.

Mr. President, it cannot be business as usual and our bureaucratic institutions need to adopt ways of fighting the real enemy of the people, HIV/AIDS, as an urgent global emergency. As we falter in our responses, as we deny additional resources to this war, as we lag behind in scaling-up our response, we, national governments and development agencies, are committing a crime against humanity-the mass death by HIV/AIDS.

With no cure in near sight to stop AIDS, our first line of defence remains prevention but we must also give greater attention to care and treatment. Large-scale prevention efforts that are gender sensitive and have the leadership of the government and the participation of communities have proved successful in Thailand, Senegal and Uganda. As cosponsors of UNAIDS, both the World Bank and UNFPA must work together and with the other cosponsors to help countries scale up their response so that information, education, counselling, as well as care and treatment spread faster than the virus spreads.

In our joint efforts to fight AIDS, we must build on and use the inroads that have already been achieved, including the channels that have been built up by the UNAIDS network. We must also work together to ensure that the Global Fund to Fight AIDS, Tuberculosis and Malaria is part and parcel of this international effort. It is truly shameful that the Global Fund generated only $2.1 billion out of a target of $10 billion.

Like all matters in reproductive health, AIDS requires a multisectoral response that reaches beyond the health system to the community. Effective strategies for behaviour change, condom programming, and targeting and involving specific sectors of society, including those living with HIV/AIDS, have been developed and need to be brought to scale to reach every citizen.

At the United Nations Population Fund, knowing that HIV/AIDS has a woman's face, we are focusing on three strategic interventions: ensuring that information and services reach and involve young people, especially adolescent girls; ensuring that pregnant women and their children can remain HIV-free, and ensuring that condoms are accessible, and used correctly and consistently. These three interventions are absolutely critical to stop AIDS from spreading. The United Nations Special Session on HIV/AIDS, 2001, has rightly adopted the ABC approach-abstinence, be faithful and condom use. In line with the consensus reached, UNFPA promotes and advocates for these three methods of HIV/AIDS prevention.

Ladies and gentlemen, women are not only the poorest of the poor but they are also the most victimized by HIV/AIDS. In Africa, two in three young adults infected are women, and infection rates among teenage girls are five to six times higher than rates for teenage boys. AIDS is fuelled by gender inequalities that must be addressed to stop the virus. Therefore, it is imperative that women are empowered to say NO to sexual relations. We must ensure the participation of boys and men and their adoption of responsible behaviour so they can protect their own health and that of the health and lives of their partners.

Gender and Poverty Reduction

Although much progress has been achieved and there is a real debate and social mobilization going on in all countries about women's rights and gender equality and equity, women and girls are still denied their basic human rights. A large proportion of women lack choices, opportunities, basic social services and basic freedoms that would enable them to escape from poverty and poor health. They are not empowered to manage their fertility and determine the number and spacing of their children.

The discrimination and violence faced by girls and women constitute the most massive and grave violation of human rights in the world today. Disparities in basic rights, in schooling, in health, credit and jobs or in the ability to fully participate in society take a direct toll on women and girls. And it is clear that the full costs of gender inequality not only harm them but their families, their communities and their countries. This was clearly articulated in the World Bank's Engendering Development Report as well as in UNFPA's State of the World Population 2000 report, Lives Together, Worlds Apart. The marching orders are clear: we must make gender issues an integral part of policy analysis, design and implementation. And perhaps nowhere is this need greater than in the development of poverty reduction strategies at the national level, in particular, and in the implementation of the Millennium Development Goals, in general.

UNFPA would like to see a much stronger focus on gender and population issues in national poverty reduction strategies. The role of social mobilization and empowering the poor, especially women, to realize their reproductive rights, is critical for poverty reduction. One challenge here is to strengthen partnerships and alliances globally, but especially at the country level to build on comparative advantages in addressing these issues. We must together ensure that greater domestic and external resources are invested in the social sector in all the PRSPs, SWAPs and other national dialogues. In this regard, UNFPA looks forward to working closer with the World Bank, especially through the Poverty Reduction Strategy Papers, health-sector reform initiatives, and sector-wide approaches.

I have argued that greater investments in population and reproductive health issues are absolutely essential to meet the Millennium Development goals to reduce poverty, mortality and the spread of AIDS. Now I will tell you another reason why we must pay greater attention to population-and that is because the demographic trends that we are now witnessing in terms of population distribution, age structure, and movement are unprecedented in their size and speed and demand a policy response.

Demographic Trends/Population Dynamics

First of all, the population of the least-developed countries is expected to triple in the next 50 years, during which time the developing world as a whole will gain another 3 billion people, while the total population of the developed countries is expected to remain basically the same.

Second, there is rapid urbanization in the developing countries. This migration to the urban centres is being driven by several factors including environmental degradation, lack of arable land and water, and dreams of a better life. Clare Short, Minister for Development Cooperation of the United Kingdom, said in her opening remarks about two weeks ago in the World Faith Development Dialogue, that the poverty of rural poor seems invisible because it is hidden behind the dignity of the people's efforts to try to feed themselves from whatever comes out of the ground. However, the poverty in cities is naked, visible and stark. Thus it is important for both policy makers and service providers to pay attention to both the urban and rural poor in efforts to reduce poverty.

Third, there are the great challenges posed by an ageing population as well as the largest ever youth generation in human history, as the Secretary-General of the United Nations, Mr. Kofi Annan, said a few months ago. While the greying of the planet is unprecedented and has reached a more advanced stage in the wealthier countries, it is a global phenomenon and many of the elderly are poor. Thus, any efforts to reduce poverty must also focus on the needs of a growing older population-a population that in most developing countries has no social safety net on which to rely in old age.

Youth and Adolescents

As I have just said, we are faced by the largest ever generation of youths in human history. There are 1 billion young people on our planet today between the ages of 15 and 24-and the conditions in which many of them are living do not bode well either for their future or ours. Too many are growing up in poverty, in conflict, or in environments where there is little opportunity or hope for a productive and dignified life. Globalization, which so far has worked more for the rich than for the poor, projects to the young people images of a better life, images of a life about which they dream but they know they cannot achieve. If we ignore the young people and our promises to them, for a better life, we do so at our own peril. The youth of the world deserve far greater attention and support. In Africa, the median age today is 18; 63 per cent of Africans are younger than 25. In the Arab world, the median age is 19. In Asia, which contains 60 per cent of the world's people, half of the population is under the age of 25. The point that I want to stress is that the current bulge in the youth population presents an unprecedented opportunity for growth and transformation if there is a concerted, massive investment in education, health care, including reproductive health, job creation and employment. It also presents an unprecedented environment for social unrest if we remain passive or limited in our responses.

In terms of health, this is the first generation to grow up with the threat of HIV/AIDS as part of their everyday lives. Half of all new HIV infections occur in young people. Five young people are newly infected each and every minute. But while youth are highly vulnerable to infection, they are sadly ill equipped to prevent it. Studies show that young people know little about the virus and how it is spread and oftentimes what they do know is nothing more than myth. The world cannot afford to stand by, as young people die from ignorance and as the virus spreads faster than our collective efforts for advocacy, information and education as well as behavioural change.

We must join forces to ensure that this young generation has a fighting chance, not only to survive, but also to a quality of life and to an active contribution to the well being of their families and their societies. Young people need education, information, counselling and reproductive health services so they can avoid unwanted pregnancy, and HIV infection. The United Nations Population Fund is making young people a priority focus. We have a comparative advantage in addressing sensitive issues of culture, gender, adolescence and reproductive health, but we all need to scale up our collaboration in this important endeavour.

As we look ahead to the future, we must stay focused on the Programme of Action that was adopted at the International Conference on Population and Development. We must also acknowledge that the issues of population, and reproductive health and rights remain thorny and sensitive issues that are often misunderstood and mistakenly portrayed and we need to respond to this situation with great sensitivity as well. Whether we greatly increase commitment and investment to population, reproductive health and women's empowerment over the next decade will largely influence whether we do or do not meet the Millennium Development Goals. It is clear that all efforts must be scaled-up drastically and in a cohesive and reinforcing approach, if we are to be successful. With greater resources effectively focused on reproductive health, we can save millions of lives, reduce the spread of HIV/AIDS, increase gender equality and reduce the poverty that afflicts so many people today. We can then say with confidence that the MDGs will be achieved.

Several initiatives have identified the resource needs for reaching the internationally agreed development goals. These goals will only be attainable through a concerted effort to mobilizing resources-both national allocations and international assistance.

The Monterrey Consensus, the outcome of the International Conference on Financing for Development, showed that there is a will to increase financial flows for achieving sustainable development, and for speeding-up debt relief. This must be translated into action and very quickly before the momentum is lost and disappointment sets in. It is urgent that resources from debt relief must be channelled for education and health services, including reproductive health, especially family planning, safe motherhood, and HIV/AIDS education and prevention as well as care and treatment. By this means population pressures and poverty will diminish, and there will be a real opportunity to achieve sustainable development.

Before I close, Mr. President, it is difficult for me not to mention culture and religion, even against the between-the-lines advice of some of our colleagues. In your opening statement to the World Bank Conference on "Culture Counts", you said the following:

"In this time of globalization, with all its advantages, the poor are the most vulnerable to having their tradition, relationships and knowledge and skills ignored and denigrated, and experiencing development with a great sense of trauma, loss and social disconnectedness. Their culture-values, social relationships, ties of reciprocity, creative expression and knowledge-can be among the most potent assets and among the most ignored and devastated by development programs. Or, if we take care, the poor can be proud of their identity and heritage and draw on these assets to enrich their lives."

When you spoke of your vision of the Bank's approach to culture, I thought I was hearing my own thoughts being so well expressed. I will here borrow the same quote by Wole Soyinka, the great Nigerian writer and Nobel Laureate that you used in your statement. He said, "Culture is a matrix of infinite possibilities and choices. From within the same cultural matrix we can extract arguments and strategies for the degration and ennoblement of our species, for its enslavement or liberation, for the suppression of its productive potential or its enchantment." You assert, Mr. President, that however culture is defined, "it is increasingly clear that those of us working in the field of sustainable development ignore it at our peril."

This is such a direct and simple message-a very principled and logical one as well. Yet, its mere thought seems to create so much resentment, fear, and/or resistance among some of our colleagues in our two organizations and even among some members of our governing boards. This reaction is further accentuated by our joint efforts to seek closer cooperation with faith-based institutions and religious leaders that believe in the development of people and the attainment of social justice for all- among countries and within countries and communities. Our experiences in the field indicate that when we accessed these institutions and community leadership, the local ownership and sustainability of the efforts could be achieved.

Mr. President, we also know that the various faith-based institutions provide about 50 per cent of the health and education services in the poor communities; we also know that they have a large constituency including women and youth; they have outreach and networks and they are credible to their people. If we want to achieve the Millennium Development Goals by scaling up the responses of all the communities, do we ignore this large investment in people? Or do we engage in dialogue and in action? Actually we need to ask ourselves-do we have a choice? You and I know we do not, but we also believe wholeheartedly that we must proceed in this direction as we do in all other directions. We cannot be but inclusive because development must be inclusive. We know that deep changes and reorientation of societies will not take place unless people are "touched in their hearts, their senses and their own mode of thinking" as was once said by Stefano Bianca of the Agha Khan Trust for Culture.

Mr. President, to achieve the Millennium Development Goals, we must ensure that they are based on two solid foundations-they extend upward to the universality of human rights and they extend downward to the specificity and diversity of the human experience. The MDGs must assume a different form than what we have given them so far-they must have a heart that throbs with the throbbing of the people's hearts.