Western population alarmists writing in The Lancet this month have their sights trained on Africa where, they claim, the family planning agenda for the developing world is "stalled". In this interview with MercatorNet, Ugandan paediatrician Angelina Kakooza-Mwesige says family planning promotion in her country is not stalled, but it must respect the moral values of people and the strong desire for children that most Africans still have. After all, why would Africans want to be like Europeans, who are dying out?  

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MercatorNet: The Lancet claims that for various reasons the family planning agenda in the developing countries has stalled. Is this something noticeable in your country?
 
Angelina Kakooza-Mwesige: The family planning agenda for Uganda has not stalled. The Family Planning Association of Uganda operates in over 30 districts. The Ugandan Government amongst other activities has also set up the Health Communication Partnership (HCP) to help the Ministry of Health and various partners implement their National Reproductive Health Communication Strategy, with an emphasis on family planning.
 
Acceptance of some family planning methods is still a bone of contention, especially with the Muslim and Roman Catholic religions, which do not favour any form of artificial contraception. The Catholic Church advocates for natural family planning with methods such as the Billings Ovulation Method. To quote the words of retired Catholic cardinal His Eminence Emmanuel Wamala, "It is true we are citizens of this world. We are members of our communities. We do not live in ghettos. We are entitled to equal treatment. We are entitled to enjoy the same rights. But we must reject lifestyles which are incompatible with the Christian faith and with the Christian way of life."
 
MercatorNet: One of the reasons identified by the Lancet for "stalling" is that AIDS has won the attention of world leaders and much more funding. Do you see this happening?
 
Dr Kakooza: At present HIV/AIDS programmes have won the attention of several donors locally and abroad which is commendable. There are quite a number of HIV/AIDS projects on the ground but these do not detract from other health issues like family planning, tuberculosis or malaria.
 
MercatorNet: To what extent are Ugandans using family planning?
 
Dr Kakooza: According to the 2000-2001 Uganda Demographic Health Survey (UDHS) conducted in almost all districts of the country, the contraceptive prevalence rate among currently married women who are using any method is 23 per cent. This represents a steady increase since 1988 when the figure was 5 per cent. Overall, the most commonly used methods are injectables (6 per cent), Lactation Amenorrhoea Method (4 per cent) and the pill (3 per cent). Compared to other eastern and southern African countries where similar data is available, the low contraceptive use in Uganda is only higher than that of Mozambique, Ethiopia and Rwanda.
 
The increase in the use of family planning methods has not yet had much impact on the fertility levels, which declined only slightly from 7.1 children per woman in 1988-1989 to 6.9 per woman in 2000-2001. Some argue that the expected benefits in fertility reduction from a rising contraceptive uptake in the country have not been forthcoming because the increase did not reach the critical level required to cause any meaningful change in overall fertility.
 
The low contraceptive prevalence in Uganda may indicate that some of these methods are still not that acceptable to the women, or that access to them is limited. This area still needs to be explored in depth. However, investigation of some of the reasons for non-use of contraceptives among currently married women has shown that difficulty in becoming pregnant (23 per cent), fear of side effects (18 per cent) and the desire to have more children (11 per cent) were the most commonly cited responses.
 
This shows that married women in Uganda still value the institution of marriage and would wish to be open to life, as marriage should be, and bring forth the children that they are able to have under the circumstances. The UDHS data also shows that the desire for many children is strong in Uganda, with 14 per cent of women with six or more children stating that they would want to have another child. For men the proportion is much higher at 45 per cent.
 
MercatorNet: The Lancet acknowledges -- with more than a hint of disappointment -- that most Africans want large families. But it also talks about "unwanted births", or an "unmet need" for contraception. Is this correct in your view?
 
Dr Kakooza: The term "unwanted births" is controversial. Is the birth unwanted by the mother, father or community at large? A number of young mothers, who have conceived children out of wedlock, go on to carry these children to term. The children are either given up for adoption, or are integrated into the extended family while the young mother goes on with her studies. These births call for responsible parenthood rather than curbing the population growth.
 
Generally speaking, Ugandan couples want to space their children rather than limit their families. The term "unmet need" is used to refer to both "spacers" and "limiters" who are not using contraception, even though their attitudes are different and so are the methods they might use. In the same way, "unwanted births"does not mean the same thing for both groups. In fact, I would not be sure what it means for any woman or couple, even though population planners seem to find it meaningful. Currently, married women in Uganda (15-49 years) are said to have an unmet need for family planning of 35 per cent (up from 29 per cent in 1995) but 21 per cent of this is for spacing and only 14 per cent for limiting of children. 
 
MercatorNet: The Lancet says of your country: "In Uganda, with a moderately severe longstanding HIV epidemic, population size is nevertheless projected to grow from 30 million today to 61 million by 2025, and further to 127 million by the middle of this century, posing huge difficulties for economic advance. Yet, President Museveni's lack of concern over the burgeoning population goes unchallenged." Your comment?
 
Dr Kakooza: These are exaggerated figures given by the authors to gain sympathy for their argument, which is unfounded. The population of Uganda according to the National Housing and Census Report of 2002 was 24.4 million. Considering a 3.3 per cent annual growth rate, the population now stands at an estimated 27.6 million. It is a predominantly young population, (children below 18 years make up 56 per cent of the population) but this can be to our advantage. Our difficulties with economic progress hinge on other issues, not a burgeoning population. This lie should be demystified. The current National Resistance Movement Government headed by President Yoweri Museveni is very committed to advancing the country's economic growth, despite the current challenges it faces, and over-population has not been an issue either for this administration or the previous one.
 
MercatorNet: What are the main causes of poverty in Uganda?
 
Dr Kakooza: The issues of poverty and hunger stem mainly from poor management and distribution of natural resources. Uganda is endowed with several natural resources, a good climate and ability to harvest crops throughout the year in most areas. There is also the recent discovery of oil reserves. It is a very fertile, well-watered country with many lakes and rivers. Coffee, tea and cotton are the major earners of Uganda's foreign exchange. The economy is predominantly agricultural with a total of 68.1 per cent of the population depending on subsistence farming, up from 67.9 per cent in 1991. This increase is attributed mainly to the Poverty Eradication Action Plan. The country is self-sufficient in food, although the distribution is uneven over all areas.
 
If timely and well-organized planning of agricultural production, marketing and networking is carried out country-wide in a co-ordinated manner, there is no reason for our people to suffer from poverty and hunger.
 
MercatorNet: Lancet also blames rapid population increase for high maternal death and morbidity rates as well as high rates of childhood deaths It says high fertility disempowers and burdens women -- amongst other things. How do you see it?
 
Dr Kakooza: The naturally growing population in Uganda cannot solely explain the link with high maternal death and morbidity rates as well as high rates of childhood deaths. The maternal mortality rate (MMR) is certainly high, at 505 per 100,000 live births, but to solve this the focus should be on the most crucial area, which is health care. There is a great need to improve accessibility to quality maternal and neonatal care countrywide.
 
The infant mortality rate, currently 88 per 1,000 live births, is mainly due to conditions like malaria, pneumonia, diarrhoea or HIV/AIDS-related opportunistic infections. The latter may also manifest as the conditions mentioned previously. Rather than curbing the population we need to set up simple cost-effective management strategies to treat and prevent these conditions. For example: having well equipped maternity facilities with trained staff, increasing the use of insecticide-treated mosquito nets, provision of safe water and strengthening the immunization services.
 
MercatorNet: Birth control can give a country like yours the "gift of demographic modernisation", according to the Lancet. What this pleasant-sounding phrase actually means is a "unique but transient opportunity to make rapid gains in living standards." Is this a good sales pitch for Africans?
 
Dr Kakooza: Not in the least! This "gift of demographic modernisation" is very selfish propaganda: with fewer mouths to feed we have more money to spend on ourselves and our own pastimes. With fewer children to support it is assumed that everyone will be much better in terms of living standards than before.
 
What is forgotten here are the dynamics of population growth. There will eventually be a great gap created as better living conditions prolong the life of the older population, which becomes less productive but is not being replaced by the young, energetic and productive youth. This presumably leads to the country getting poorer again, or at least slowing down economically. This is the threat that the industrialised countries face at the moment and, amazingly, want to "sell" to Africa. This is unacceptable!
 
MercatorNet: Do women in your country need "freedom from the tyranny of excessive fertility" as the Lancet suggests? Is their fertility preventing their equality in society, their education and so on?
 
Dr Kakooza: On the contrary, Ugandan women do not need any freedom from the so-called "tyranny of excessive fertility" which in the first place does not exist. The desire to have children is still strong and family values are greatly encouraged. Most Ugandan families even take care of children who are part of the extended family in addition to their own biological children. Women's fertility poses no threat whatsoever in terms of equality in society, job opportunities, education or recognition in society.
 
MercatorNet: The authors talk openly about the need to change the culture of a country like yours regarding family size. They see the need to create moral "legitimacy and awareness" of contraception, through a broad coalition across society that can win political commitment. Mass media would be an important part of this. How does this programme sound to you?
 
Dr Kakooza: Sheer nonsense. Our culture should be emulated instead of being discouraged. What we are seeing across Europe is the shrinking of the young, energetic and productive population and expansion of the old, ageing and heavily dependent population. Increasingly they rely on the immigrant population with their larger families to fill this gap. So what will happen if they shrink our populations too? The whole idea is utterly ridiculous. The mass media should be used for promoting family values not contraceptive legitimacy or awareness.
 
MercatorNet: Nevertheless, they want to see family planning integrated into all sorts of public and community services in order to speed up the process. This smacks of pressure tactics -- do you agree?
 
Dr Kakooza: Yes, I certainly do. The planning of a family is a private affair undertaken by the couple to space their children accordingly. Integrating family planning into all sorts of public and community services is like intruding on the privacy of these couples and forcing them to take on methods that may not be desirable for them. Both partners should be committed to practicing an acceptable family planning method that suits them rather than have some method forced onto them. The discussion of this delicate issue among couples encourages stable and committed relationships as well as improving their communication about their bodies and their sexuality.
 
MercatorNet: The various methods of contraception are said to be safe for women. Is this true?
 
Dr Kakooza: No! The authors seem to regret that the most "cost-effective" methods -- sterilisation and IUDs -- have been tainted by coercion in other countries (India, China, Vietnam). The question is: How cost-effective is the IUD when it tends to cause disabling symptoms and complications like irregular heavy painful periods, unbearable cramps, nausea, miscarriages due to scar tissue from tubal infections or uterine perforations? The emotional stress that some couples go through when all hope of obtaining a child is gone due to irreversible complications of the IUD can never be cost effective!
 
They also propose injectables and the pill as being the best methods for Africa. The criteria for this choice are not that clear, but in any case how safe are they? These hormonal based contraceptives carry an inherent risk of serious complications that can be life threatening, such as blood clots in the veins, heart attacks or stroke -- especially if there is a history of smoking -- and other complications like hypertension or growths in the liver may occur. Even if these side effects are rare, they can still be fatal, and how many women, when they are fully informed, want to run that risk?
 
MercatorNet: The Lancet calculates that it would cost $3.8 billion over 10 years to halve the birthrate in Africa and so meet the UN's medium-variant population projections. What would you rather do for Africa with $3.8 billion?
 
I believe the following are top priorities:
·        Development of cost effective energy solutions, like solar energy, hydroelectric power, in, most areas.
·        Improvement and set up of infrastructure to enable fast and effective communication and road networks.
·        Provision of safe and accessible water sources.
·        Equipment of standard health care facilities to provide holistic care to patients.
·        Provision of universal primary education.
 
Dr Angelina Kakooza-Mwesige is a paediatrician working in Mulago National Referral Hospital in Kampala, Uganda. This hospital is also home to Makerere University Medical School, the first medical school in East Africa, where Dr Kakooza-Mwesige is an honorary lecturer. Her special interests are in clinical neurology, especially the conditions of epilepsy, cerebral palsy and autism in children, as well as HIV/AIDS.