Malcolm Potts, Virginia Gidi, Martha Campbell and Sarah Zureick
NIGER: TOO LITTLE, TOO LATE

[In a world of Seven Billion, this is a cautionary tale for us all. What happens when a culture tells girls to value early marriage, servitude, no education, and no family planning? What happens when millions of desperate people flee their homelands? ~Editor]

With the world's fastest growing population, highest total fertility rate, rare and diminishing arable land, limited rainfall, high levels of malnutrition, extremely low levels of education, gross gender inequities, and a likelihood of conflict over diminishing resources, Niger presents us with a challenge for which we are not yet prepared. Niger is the most extreme example of a catastrophe that is likely to overtake the entire Sahel region of Africa.

Climate change could overwhelm an already fragile ecological environment. We examine two broad policy options: (1) the past policy of focusing on socioeconomic development and largely ignoring family planning; (2) the emerging emphasis on family planning choices. We conclude that the only plausible scenario for Niger is to prioritize family planning as a critical factor for development, and also delay the age of marriage. All the countries of the Sahel could be facing mortality in next 30 years that will match Africa's deaths from AIDS over the past 30 years.

Thirty-four African countries have population growth rates over 2.5%, and 12 over 3%. Many of the countries in the sub-Saharan Africa region, such as Burkina Faso, Malawi and Uganda, face the challenges of rapid population growth, limited human capital and diminishing agricultural and other resources. Much of the Sahel has already exceeded the capacity of local agriculture to feed their populations, education levels are low and non-agricultural employment opportunities are not developing. The status of women is exceeding low, especially in the Hausa speaking, polygamous societies of which Niger is a harsh example. Conflict, as in Darfur, is partly driven by competition over scarce resources.

THE PROBLEM
Demographics and family planning norms

By mid-2010 the population of Niger was estimated to be approximately 15.9 million with a total fertility rate (TFR) of 7.4, and it is projected to reach 58.2 million in 2050, assuming the TFR falls to 3.8, which is by no means certain. In 2050, Niger is likely to be the second most populous country in West Africa. Also, at that time the population will still be growing and the number of women aged 15 to 49 will be greater than the total population of all age groups and both sexes in 2005. An analysis of family planning trends in 13 West African nations, including Niger, by Cleland, Ndugwa and Zulu finds that contraceptive prevalence in the region was increasing by only 0.6 per cent per year, strongly suggesting that the United Nations population projections are unduly optimistic.

Until recently, there was little change in Niger with respect to contraceptive prevalence, and consequently its population size has continued to grow at a rapid rate. Over one quarter of women aged over 40 have 10 or more children. Approximately 49% of the population is 15 years of age or younger, and only 3% are 65 years or older. Unlike many other African nations HIV prevalence is less than 1%.

Family and cultural dynamics are important. The median age of marriage for women is 15.7 years and does not appear to be changing. Niger has not ratified the Maputo Protocol outlawing early marriage. Niger is one of the few countries in the world with little or no overall unmet need for family planning, meaning that desired family size is higher than actual. In 2006, married women reported wanting an average of 9.1 children, married men 12.6 children, and a previous DHS survey revealed the polygamous men reported wanting 15.3 children. Only one in 100 women want to have two children and those who have 6 plus children say they would like to have 10. Only one in nine couples use any form of contraception.

Development

In 2008, Niger ranked 174 out of 178 countries on the Human Development Index, with more than 60% of the population living on less than U.S. $1/day. The Gross National Income in 2008 is one of the lowest in the world. Recent economic growth (approx 2%) is lower than the population growth (over 3.9%).

Many tens of thousands of people are thought to live in conditions of traditional slavery. Children are forced into domestic servitude and work in the mines, and women and young girls are trafficked for sexual exploitation and domestic servitude. Only 15% of women have any primary school education, and as of 2006 only one in 100 completed primary education. Only one in 1,000 women completed secondary education. It seems extremely unlikely that investment in education will get ahead of rapid population growth. The school-age population will be eight times as large in 2050, yet over the past decade the share of the government's general budget going to education has fallen from 15% to below 10%. The number of primary school classrooms has decreased due to lack of upkeep and unavailability of teachers. Lack of education has clear implications for the overall development of the country.

Given these conditions, it is highly unlikely that Niger will have enough health care professionals to meet the needs of its exploding population. In 2000 there were 226 doctors, 13 pharmacists, 1,128 nurses and 334 midwives serving a population of 10.7 million people. In 2007 there was no evidence of significant progress with regard to increasing the number of health professionals.

Environmental Issues

The Sahel is one of the most fragile ecologies in the world. Rainfall in the Sahel decreased 29% to 49% in 1968-1997 compared with 1931-1960. In Niger, measured against a 1961-1990 baseline, rainfall is projected to decrease a further 10% to 20% by 2025. Between 1975 and 2050 the population will have increased from 4.9 million (1975) to 26.2 million (2025 medium estimate). Only 12% of Niger's land area can sustain rain-fed agriculture. In 2010 the temperature reached a record 118o F. Climate experts predict that rain-fed agriculture could disappear from Niger by 2100.

Rapidly expanding populations in sub-Saharan Africa depend heavily on monsoon rainfall for agriculture and power generation and are ill prepared to adapt to severe droughts. Across the Sahel as a whole, the droughts in the 1960s and 1970s led to a decline in GDP (which is largely based on agriculture), migration from north to south, migration to shanty towns in cities from desiccated rural areas, and an estimated 100,000 deaths.

Niger's soils are low in nutrients, poorly managed, over-grazed and losing up to 100 tons of top soil from erosion per hectare per year. The demand for firewood for cooking (two million tons annually) is twice the rate of natural growth. Subsistence farmers and pastoralists in this land-locked country have weak links to markets, a low use of external inputs such as improved seeds and fertilizers, and they lack financial institutions to lend money or insure against external shocks—and the animals people own as a capital investment die when the rains fail. Water scarcity and degradation of land is likely to increase. While the population has been growing at 3% per year, grain output has been falling 0.6%. New crop varieties of drought resistant millet, sorghum and cowpea are being adopted and more research and investment in agriculture is needed urgently. However, it seems unlikely that the yields will keep pace with the population growth.
Approximately 10% of children under five in Niger suffer from acute malnutrition and 44% of children suffer from chronic malnutrition. The United Nations Economic Commission for Africa recently reported that in Niger children aged two or younger were 72% more likely to be stunted if born during a drought.

Future Scenarios

Predicting global warming at a regional or national level is difficult and some models actually predict higher rainfall as the Sahara heats up. However, most climate scenarios paint a somber—even frightening—picture. According to the United Nations Environment Program, "unfortunately, the Sahel is almost inevitably heading towards an environmental disaster". Meeting the first Millennium Development Goal of cutting in half the proportion of poor and hungry people by 2015 is "mission impossible."

A likely scenario is increased variability in summer rains leading to droughts every two out of five years and major droughts every 10 to 20 years. In the 1960s the population of the Sahel was 25.5 million: by 2015 it is projected to be 88 million. The already high levels of malnutrition are likely to increase, and even without large scale starvation, death rates, especially among infants, are likely to rise. The social networks that currently protect families against external shocks will collapse under the growing number of people who will slip from chronic poverty (when for some parts of the year they will have to borrow money or rely on their extended families for food) into persistent poverty (where year-round they will depend on relatives or external aid agencies for food and daily necessities).

The easiest to predict scenario is that more and more food aid will be needed from the international community. However, with the rising cost of grain and competition for food from emerging economies (for farm animals as well as people) it is possible that external food supplies may not be sustainable. Managing outside humanitarian aid could become increasingly difficult; over 30 aid workers have been kidnapped in the past two years in the Sahel.

As the population of agriculturalists and pastoralists grows, as the land becomes increasingly overused, millions will migrate to urban slums. Many may try to move south, entering northern Nigeria and other parts of West Africa.

The prospect of hunger and societal breakdown on an unprecedented scale has to be faced. The 'brown streak' virus, now attacking cassava in the Great Lakes region of Africa, could spread to the Sahel. If this happens, Niger will then be like Ireland in the 1840s—a country with rapid population growth that suddenly loses a staple crop and suffers catastrophic starvation.

Rapid population growth and diminishing food, firewood and other resources are likely to increase the risk of conflict. Using regression analyses on past temperature changes and projected future climate change, research suggests a roughly 54% increase in armed conflict incidence by 2030 across the whole of sub-Saharan Africa.

POLICY OPTIONS

Two primary and partly opposed policy options exist in relation to slowing rapid population growth. One is to emphasize socio-economic improvement which many assume will drive lower fertility—"development is the best contraceptive." The other is to give much greater weight to fertility regulation/ family planning.

Socio-economic improvement

Economists in the World Bank and elsewhere continue to be influenced by the concept that development is the primary driver of the demographic transition and often give little more than token support to investing in family planning. Until recently, this has been the picture in Niger and as a result the country has built up a great deal of demographic momentum.

A 'free market solution' in fertility regulation never existed because (1) the population lacks the resources to participate in it; (2) there is no wide availability of contraceptive options; (3) abortion is illegal; and (4) most people do not have sufficient information to make informed choices.

In Niger, even the International Planned Parenthood (IPPF) affiliate, the Association Nigérienne pour le Bien Être Familial (ANBEF), lists HIV prevention, male and female infertility, and training young people on income generating activities, but does not use the words 'population,' 'family planning' or 'contraception'.

Emphasize family planning

This policy in no way denies the imperative for investing in human capital, reducing poverty and improving the status of women, but it asserts (1) that these investments will not by themselves reduce rapid population growth within a foreseeable time horizon; and (2) that a vigorous, strategic emphasis on fertility regulation is a necessary factor for achieving smaller average family size—although not by itself a sufficient factor for socioeconomic development.

Meeting the unmet need for voluntary family planning by providing a variety of contraceptive methods and countering misinformation about contraception is a logical and necessary starting place for fertility reduction. It is the one policy option with a glimmer of success. Although the stated demand for family planning in Niger is low, even so only 42% of the known demand for family planning is satisfied. Furthermore, desired family size is a moving target. For example, when the rapid fertility decline in Iran began in 1990 and the TFR was 5.5, women did not report that they want the two child family, which they achieved only 10 years later.

We define access to family planning as not only access to contraceptives themselves but also access to accurate, culturally appropriate knowledge. Countering misinformation is also an essential component of making meaningful access to family planning universally available.

The age of initiating sexual intercourse is a key variable influencing the TFR. The mean age of marriage in some areas is below 14. Older, richer men engage in polygamous marriages with teenage brides. A young bride often has to adjust to the presence of an older wife, and she is often cut off from frequent contacts with her biological family. Domestic violence is common. Early childbearing consumes her energies and further narrows her options. Vesico-vaginal fistulae are a tragic complication of early childbearing.

Strategies for postponing the age of marriage are limited. Pilot projects in Hausa communities in Nigeria have found that small cash payments can tip parents' interest in keeping a girl in school. Where school is not an option, experimental mechanisms for setting up girls' groups, where young women can learn about their bodies and understand that choices can be made about family size, are being explored. Could conditional cash transfers for delaying marriage be brought to scale? Could they have perverse consequences, for example would the older girls who delayed marriage be considered less attractive as brides?

WHAT NOW?

An objective examination of the current situation and of foreseeable demographic changes in the coming decades leaves a focused, initially stand-alone, family planning program as critically important and the only achievable policy strategy. Efforts to raise the age of marriage are much needed but may take time to develop.

Population growth at the pace found in high fertility African countries undermines any plausible strategy to lift people out of poverty through economic development. While it is true that a Nigerien woman with secondary education has an average of 31% fewer children, only 0.1% completed secondary education. UNESCO recognizes, "Due to continued population growth, the least developed countries, which are furthest from universal participation at primary and secondary level, especially in sub-Saharan Africa, will face increasing enrolment pressure in coming decades." If education fails to catch up with the demographic growth, then there is no possibility of educating ever increasing numbers of illiterate young people.

Niger and other countries in the Sahel must live with the past mistake of too little too late, but rather than calling for family planning as one item in a comprehensive reproductive health program, stand-alone family planning services should be welcomed.

Family planning is an informed choice, not the diagnosis of a disease, yet the adoption of family planning can prevent infant and maternal deaths, even before any improvement in clinical services. If Niger is to take any significant steps towards achieving Millennium Development Goal 3 to promote gender equality and empower women, then in the words of the WHO, "Although women's ability to control their fertility is by itself not sufficient to gaining their full empowerment and gender equality, it the first and most important step."

Unfortunately, demography is an unforgiving taskmaster and the demographic momentum now found in Niger and similar countries casts a threatening shadow. An objective review of possible scenarios for the Sahel as a whole suggests the possibility of a humanitarian catastrophe unfolding over the next 30 years. It is imperative that local governments, international agencies and donors, and anyone with a commitment to lifting people out of abject poverty and improving the health of women and children, join in a vigorous effort to take the best practices from earlier family planning programs and apply those practices to launching large scale voluntary family planning in Niger, and in the other suffering countries across the Sahel.

We suggest that 'coercive pregnancy,' in the sense that women do not have the information or access to family planning they need in order to exercise their right to choose when to have a child, is as ethically deplorable and as unacceptable as coercive family planning.

Source: Potts, M et al., "Too Little, Too Late" International Perspectives on Sexual and
Reproductive Health, 2011, 37(2):95-101 (journal of the Guttmacher Institute). Adapted with permission from the Guttmacher Institute. To read the entire article, including citations and charts, go to: http://www.guttmacher.org/pubs/journals/3709511.html

Malcolm Potts, MB, PhD, holds the Bixby endowed chair in Population and Family Planning in the School of Public Health, University of California-Berkeley, CA. He has published ten books and over 200 scientific papers. His most recent book is Sex and War: How Biology Explains War and Terrorism and Offers a Path to a Safer World.

Virginia Gidi, DrPH, is a fellow with the Bixby Center for Population, Health & Sustainability, University of California-Berkeley, CA.

Martha Campbell, PhD, is president and founder of Venture Strategies for Health and Development, based in Berkeley, CA.

Sarah Zureick, PhD, is a postdoctoral researcher at the Center for Demography and Ecology, University of Wisconsin-Madison, WI.