“…the tide of the battle against hunger has changed for the better during the past three years. But tides have a way of flowing and then ebbing again. We may be at high tide now, but ebb tide could soon set in if we become complacent and relax our efforts. For we are dealing with two opposing forces, the scientific power of food production and the biologic power of human reproduction. Man has made amazing progress recently in his potential mastery of these two contending powers.
“But [man] is not yet using adequately his potential for decreasing the rate of human reproduction. The result is that the rate of population increase exceeds the rate of increase in food production in some areas.
“There can be no permanent progress in the battle against hunger until the agencies that fight for increased food production and those that fight for population control unite in a common effort.”
Norman Borlaug, 1970, Nobel Prize Acceptance Speech

            The North American southwest is experiencing the worst drought in over 1200 years, endangering the livelihood of millions of people. In contrast, in Africa, where many people already live on the edge, the risk is to their lives.
            Here, there is less snow, and it is melting sooner. Rivers are running low and reservoirs are shallow. Ranchers and farmers are suffering from the drought. We know that half of our megadrought is due to climate change. Furthermore, we know climate change is largely due to CO₂ from using fossil fuels.
            In many places, Africans are also experiencing drought. Paradoxically, there is destructive flooding elsewhere in Africa. Drought there is not because Africans are using lots of fossil fuels, of course. The average annual income of a person in Sub-Saharan Africa 1/15^th that of the average American; we consume much, much more. People in Africa simply cannot afford the extravagance of fossil fuels we take for granted.
            It seems unfair that our consumptive lifestyle should lead to famine in other parts of the world, but it is difficult to escape that conclusion.
            However, some of the responsibility for the famine in Africa may rest on the shoulders of a Nobel Prize laureate for peace, although he certainly warned us about growing population in the quote above. Norman Borlaug has been called the father of the Green Revolution because he developed agricultural innovations that increased crop productivity markedly. More food allowed populations to increase—when there was adequate rainfall. However, more productivity has its costs. Expensive non-native seeds must be purchased, and more productive plants required chemical fertilizers, herbicides and other chemicals to grow, yet often depleted the soil.
            Now, with more people and less rain, crops are failing. People have debts that they cannot pay. Animals are dying from thirst and lack of forage. There is an excellent but sad report in the NYTimes on the famine: “’We Buried Him and Kept Walking’: Children Die as Somalis Flee Hunger”. I had to turn away before finishing.
            The African famine reminded me of the great question that faces scholars of Southwestern archeology: why did the Ancestral Puebloans leave the Four Corners region? A series of wet years preceding the departure allowed the population to grow. It is likely that the human population overshot available sustenance during the megadrought of the 1250s. Did the people move because of famine? This theory is supported by evidence of severe strife and bloodshed before the exodus.
            Should we help Africa with food relief? Unfortunately, that would encourage people to congregate near food distribution centers, away from farms. Even though relief will save lives in the short run, it will make people more dependent on foreign aid, and won’t solve the problem of overpopulation. I don’t know what the most humane thing to do is. Perhaps we should follow the advice of a friend who only donates to relief agencies that also provide family planning.

In Africa, as elsewhere in the world, religious beliefs have an influence on the number of children a woman will bear. There are many factors that go into family size choices, and religion is one that is rarely explored.

In the USA, Utah is an example of how religion influences family size. It has had the highest fertility rate, probably in part because of its large number of Mormons (Latter Day Saints). This religion has traditionally encouraged large families, and many Utahans have complied. I know an example from my practice. An LDS patient from Utah requested reversal of her tubal ligation, which was done after her 5^th child was born. She regretted the sterilization and wanted more children. I succeeded in putting her tubes back together, and she ended up with 12 kids!

In many African countries—especially south of the Sahara—the predominant religions encourage high fertility. Many groups of both Christians and Muslims believe that children are gifts from God and feel that contraceptive use is prohibited. Part of the motivation for large families seems to be that there is strength in numbers—especially if a group feels threatened. In addition, agrarian people tend to look upon children as a resource for work, while urban societies may consider kids financial burdens. Furthermore, rural people have less access to contraception than those who live in cities. A third major group of religious believers, those who follow traditional faiths, tend to have many children, perhaps because they are more likely to be subsistence farmers.

What can be done to help women get effective birth control? IUDs and implants, the most effective temporary contraceptive methods, are expensive and require skilled providers. Fortunately, a promising new variation of an old method has won favor in several African countries. For over 50 years women have trusted DMPA (DepoProvera®) for contraception. It is very effective, but requires a shot every 3 months—which is especially difficult for rural women. Some women have sickle cell anemia, an inherited disease in Black Africans, which causes painful crises. DMPA can actually prevent these crises in addition to preventing pregnancy!

Sayana Press® is the same medication in a more convenient form. In a trial, Ugandan women who chose Sayana Press® were taught how to give themselves the first shot in a clinic. They went home with 3 more shots to self-administer at 90-day intervals. This meant only one clinic visit a year—much better for someone who might need to walk miles or take an expensive bus to the nearest family planning clinic.

Education is an important way to empower women and for them to gain control of their fertility. Perhaps this teaching could include mention of the advantages of smaller families. In Sub-Saharan Africa, as in other parts of the world, the more years of school a girl or woman attends, the smaller her family is likely to be. Joyce Asimit Simiyu of northwest Kenya is a good example. She is the oldest of seven kids. Although elementary school was free, her family didn’t have resources for her to go to secondary school. The Quaker Girlchild Education Fund provided scholarship aid for high school and eventually she finished college. She and her husband are the parents of only two.

There are innovative ways that family planning services are delivered in Africa. Catholic dogma is against modern contraceptive methods, but people have found ways around that doctrine. I asked a Catholic nun who runs a health center in Tanzania if they provided contraception. “No,” she said, “we leave that to the Protestants down the road.” Rwanda is another example, where much of the health care is provided by the Catholic Church. After the 1994 genocide, the government recognized the importance of family planning and placed a family planning clinic close to each of the Catholic facilities.

Many places in Africa already exceed the land’s ability to feed its people, yet the world’s fastest growing populations are there. What works to slow growth? In many cultures religious leaders are key to promoting successful family planning. Although they may not be interested in slowing the growth of their congregation, most leaders will want to improve the health of their mothers and children. One of the best ways of doing that is with contraception to lengthen the interval between pregnancies.